Does leaving against medical advice stick patients with a bill?

(All names and identifying features of characters in this story have been changed.)

Nora, a third year medical student, came to me in moral distress.

Ms. DiFazio, one of the hospitalized patients on her internal medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.

The first year doctor with whom Nora was paired, Dr. White, vented to her:

“These patients come to us seeking our help and then refuse what we have to offer them,” Dr. White steamed.

At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond “I don’t want to” was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.

By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out ‘against medical advice’ (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.

“The threat of a huge hospital bill got Ms. DiFazio to stay and take the test,” Nora related. “It just seems so wrong to bludgeon a patient this way. Can it possibly be true?”

I’d been out of medical school myself for eight years at that point; until then I’d never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient’s freedom of choice, or as we like to call it in medicine, their autonomy?

I told Nora I didn’t know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘preexisting conditions,’ a mere grain of plausibility made this idea seem vaguely credible.

I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.

I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?

From their attendings.

From the nurses.

From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.

We needed to find the truth.

Colleagues helped us sift through nearly ten years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid—and that was invariably due to ‘administrative issues,’ not because of the AMA discharge.

I also thought it important to go to the source: I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation’s largest private insurance carriers.

Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk: nothing more than a medical urban legend.

They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company’s own medical directors—a half dozen of them–and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.

So patients and doctors beware: The next time you or your loved one has decided that it’s time to leave the hospital, don’t let us doctors coerce you into staying by threatening you with the bill.

It simply isn’t true that leaving against medical advice makes it fall entirely upon your pocketbook.

Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won’t have to submit to procedures that they don’t wish to undergo.

John Schumann is an internal medicine physician who blogs at GlassHospital.

This story was one of the winners of the Costs of Care 2011 healthcare essay contest, with the goal of expanding the national discourse on the role of doctors, nurses, and other care providers in controlling healthcare costs.  These stories from care providers and patients across the nation illustrate everyday opportunities to curb unnecessary and even harmful health care spending on a grassroots level. 

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  • Kevin T. Keith

    More than that, there is no obligation on a patient to sign anything when leaving the hospital. “Signing out” AMA is itself a ritual devised by hospitals both to browbeat patients and to slough off liability. But the hospital has no legal right to keep any (legally competent) patient who wants to leave, for any reason. You simply may not imprison your patients – nor imply to them that they are imprisoned until they agree to your terms.

    What is more shocking in this case is the attitude that patients may be pressured to accommodate medical staff in the first place. It’s good to set the record straight about the bogus canceled-insurance myth, but the idea that the house staff felt they were empowered to take advantage of a financial burden they (mistakenly) believed existed in order to get the patient to comply with their treatment recommendation is even more distressing than the myth itself. There are plenty of ways to apply pressure to patients; the important thing here is not to point out that one of them is ineffective, but rather that all of them are wrong.

    • Anonymous

      Mr. Keith,
      I was also trained to believe that patients leaving AMA may have to foot the bill.  I am glad to know that is not the case. I also believe patients should not  be coerced into receiving care against their free will. However, I also believe Physicians have the right to document clearly in the chart that the patient understood the risks of not following the recommended course of action in order to protect themselves from the potential of a future lawsuit  brought by the patient or their surviving family members. I would not characterize asking a patient to sign an AMA form ( which they have the right to refuse to sign) as ” sloughing off liability” but rather asking the patient to assume responsibility for their own actions, a concept that appears to have fallen out of fashion in modern society.

  • ninguem

    I was told the same thing…….the exact same thing……THIRTY YEARS AGO as an intern.

    It was a myth then, and it’s a myth now.

    Signing out AMA has no effect on insurance coverage of services provided up to the time of signing out AMA.

    Anyone has evidence to the contrary, I would like to see it. All these years, I have yet to see any such evidence.

    I am appalled to see the myth continues. I wonder how many other myths from generations ago, still persist in teaching hospitals?

  • Mark Arnold

    If a patient is coerced he is no longer a partner, what if there is a bad outcome, then what? 

  • Anonymous

    From the article, it sounded like it was the first year resident who determined the patient needed the cardiac catherization. Would he have the sole authority so early in his training?

  • Anonymous

    I’m not sure I’d want someone like that first year resident graduating from my program UNLESS they had a major attitude adjustment, but then, attendings in the department might be promulgating that attitude.  Usually when a patient is apparently unnaturally afraid, there is a communication issue, and an opportunity to improve communication.  Intimidating the patient is not the way to go.  What a sad statement about the lack of quality in medical education for the student and post graduate training for the resident.

  • Anonymous

    Loved learning the answer to this as a number of years ago my husband was told the same by his cardiologist for refusing to have a cardiac catheterization, would be responsible for all bills. The situation was so bad after he left the hospital that it took him 5 years to come to terms with his health issues. This past summer he did go back to the doctor, had a consult with a cardiac surgeon & had a triple bypass in October. I handled my husband over 6 months with kid gloves, as strong a man as he is when it came down to it he was absolutely petrified. I am grateful that the doctors finally took a step back & changed how they managed him & let him go through the procedure & surgery on his terms rather than control him because I am the doctor. Great article.

  • R Bowman

    I’ve always hated this idea/practice in medicine, that if the patient doesn’t do things exactly the way we want, we won’t treat at all…   We should respect patients’ choices, even if they may not be the options we would choose for ourselves or our family members. I saw it way too much in residency.  We threatened people with “AMA” all the time.  I never knew it was a myth until now.

  • Anonymous

    I’m fine with any doctor who refuses to treat me because I don’t want to go along with his/her program.  I would much rather have that than have somebody who feels that it is their place to try to frighten or coerce me into doing thangs that *I* don’t feel are in my best interest.  I can find somebody else who is capable of handling the situation without this kind of tactic!  Just as I will never give up my right to decide what treatments I will allow.  I don’t see where this kind of reaction from medical personnel invites trust…  Interestingly, I had no problem signing a paper that said that I was leaving AMA.  I will rethink that because it kept me in the hospital refusing treatment for a very long time, while they continued charging my insurance carrier for my presence in the room.  I also wish that that so-called “INFORMED” consent had half the stuff on it that the AMA paperwork had.  I guess we are all supposed to surrender our rights at the hospital regardless of what the law says.  It’s all about what the staff wants and they will use any means necessary to obtain compliance, to include threats of horrendous medical bills.  Why didn’t they just give the patient Versed and then pretend that the patient agreed to all of it?  That’s what they did to me last ime.  No ability to sign out AMA if you are drugged out of your mind.  The added fillip to the use of Versed is that the staff can then claim that they had your complete cooperation and consent. 

  • Peter Schwimer

    And no one can force a patient to sign out AMA.  There is no legal means to restrain a patient if he/she wants to leave the facility.  Any adult voluntary patient can simply walk out the door absent a court order (ie: psychiatric committment or similar).   

  • Anonymous

    my understanding was not that they would not pay for the current hospital bill, but the next one.  If,by declining the prescribed course of care results in a preventable complications, the insurance company would not pay THAT bill.  Again I learned this from hospital staff as well, but it makes more sense to me logically.  Can we debunk that one as well??

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