JOAN PORCARO: Welcome to the WTW Vital Signs podcast program. My name is Joan Porcaro. And I am the senior vice president of risk services for WTW Health Care. I'm very excited, as today's podcast continues our newest series designed for physicians, providers, and medical practices. This podcast series is dedicated to helping health professionals navigate the complexities of medical practice with confidence and peace of mind. And in each episode, we'll delve into practical strategies, expert insights, and real-world case studies to empower you with the knowledge of tools needed to minimize legal risks and enhance patient safety.
In today's podcast, we will focus on the topic of terminating the physician and patient relationship. There's a variety of different ways to cover on this. So today's session is the first within a series on this very topic. Like any relationship, the effort to maintain a therapeutic and respectful connection between the provider and patient takes effort and time.
And like any connection between two parties, the relationship can reach a point of disruption or challenge. Ideally, working through the rough patches is always the desire. Circumstances may reach a point, though, where the differences are too far apart, the bond broken, and mutual respect lost. All efforts to resolve the matter have been exhausted. As the saying goes, breaking up is hard to do.
Today, we are joined by Myka Whitman. Myka is the lead senior risk consultant at MedPro Group, where she oversees the Southeast, Mid-Atlantic, and Puerto Rico consultant teams for the nation's leader in health liability coverage. With over 25 years of healthcare experience, including 15 years focused on risk management and patient safety, she has served as the chief risk officer and patient safety executive for several large, complex health systems.
A registered nurse with a background in emergency trauma care, Myka holds a master's degree in health care administration and holds several certifications to include Fellow of the American Society of Healthcare Risk Management. Myka actively serves on the ASHRM Advisory Board and on the Florida Board of Directors as well. Welcome, Myka.
MYKA WHITMAN: Thank you, Joan. I'm so excited to be presenting with you today. We always have such energetic conversations.
JOAN PORCARO: Thank you, Myka. So, let's begin. We both have had work experiences at the practice level at the carrier consultative level supporting the professional physician practice teams. So, to start off with what is termination of a physician and patient relationship?
MYKA WHITMAN: Joan, I think you described it well. As the health landscape continues to shift, we're driven by evolving patient behaviors, provider burnout and the increasing system pressures. So, the question isn't if a patient and provider relationship will need to end, but when and how they should?
Health care providers have the right to treat the patients they wish to treat, and to terminate relations with patients for various reasons. You talked about a few, but nonadherence to treatment, disruptive behavior, frequently missed appointments, that type of behavior. However, providers should use caution when discharging patients from their care to avoid violating laws or facing allegations of patient abandonment. And that's what we're going to talk about today.
JOAN PORCARO: Thank you, Myka. So, you mentioned it. You started to bring that conversation up. What are the most frequent reasons physicians decide to terminate a patient relationship?
MYKA WHITMAN: One of the most common reasons is patient behaviors, which may include noncompliance sometimes despite multiple efforts communication with the patient just remains unsuccessful. Additionally, several ongoing concerns have been noted in recent times. Patients consistently missing or canceling scheduled appointments may be a reason. Recommending screenings and treatments have been repeatedly declined by the patient.
Patients and family members have exhibited ongoing rude, hostile, or even threatening behavior towards providers and their staff members, or there may just be a fundamental incompatibility between the patient and provider making a collaborative therapeutic relationship unworkable. These are the most common types of behaviors or rationales for patient terminations.
JOAN PORCARO: When I'm thinking about something, before we go into a little more detail about the reasons, how do ethical guidelines shape the process of ending a physician-patient relationship and what principles must always be upheld?
MYKA WHITMAN: Absolutely. So ethical guidelines for ending a physician-patient relationship are grounded in the principles of the continuity of care, respect for patient autonomy, and professional responsibility. These guidelines ensure that the termination is handled in a way that protects the patient's well-being and maintains trust in the medical profession.
JOAN PORCARO: You're already touched upon some of the reasons why a termination would happen. And we talked a little bit about it already. When we think about treatment noncompliance, we think about that the patient does not or will not follow the treatment plan or maybe violated the established behavior or pain management contracts. And then any attempts to resolve any barriers that support resolving noncompliance or adherent behaviors have been unsuccessful. What other thoughts come to mind?
MYKA WHITMAN: Follow-up and non-compliance with follow-up. If the patient is repeatedly canceling their follow-up visits, or they continue to have no shows, this is demonstrating a pattern of noncompliance. And without patient compliance with the treatment plan, it is difficult to maintain that therapeutic relationship and trusted relationship with the provider.
We did speak a little bit about treatment noncompliance, but for patients who will not follow the treatment plan or has violated, like you mentioned, an established behavioral or a pain management contract, if your attempts to resolve any of those barriers that supported their reason for non-compliance or non-adherent behaviors have been and unsuccessful. So I think it's important to keep in mind.
One of the most valuable insights to discover when a patient is non-compliant is the rationale for noncompliance. And if that has been addressed and they're still repeated behaviors of noncompliance, it may be time to terminate that patient-provider relationship. Office policy noncompliance. Just refusal to abide by the office rules that can lead to termination of the relationship.
And unfortunately, one of the reasons for patient-provider terminations that we've seen an influx in the last couple of years is that abusive or violent behaviors. And this can be anybody in the medical office setting, from your front desk staff to your clinical staff to the provider. If a patient continues to exhibit rude, threatening, offensive, demeaning, hostile language even outside of physical threats or physical outburst. That's a good reason to consider patient provider termination.
Chronic abuse or misuse of medications or controlled substances. Refusal to seek treatment for substance abuse or refusal to abide by a therapeutic contract. Drug seeking behaviors. Obtaining controlled substances concurrently from multiple providers. If that behavior is discovered, absolutely, that would become a threat to the relationship.
And then we've talked about some of the verbal types of behaviors. But if there's any theft or destruction of the practice office setting, throwing of chairs, punching holes in the walls, throwing things. That's also a very good reason to review the patient provider termination clause.
JOAN PORCARO: And in thinking about the other aspects, sometimes when patients are making unreasonable demands on the physician's time or they ask for care or treatment, that's beyond the scope of that specialty or that plan of care, it is very reasonable to have to take the next step, which may be, of course, you want to try to resolve the situation, but you may reach a point where that termination needs to take place.
We're going to touch on a little bit later what happens when a patient has filed an illegal action, or board complaints against the physician, and whether or not the provider has any obligation to continue care. But sometimes there's really a normal, ordinary business reason, the relocation of the medical practice, retirement or discontinuation continuation with a specific health plan or even a specific specialty. So I think we've already highlighted some of the good reasons that do come up.
But then again, what types of situations are exceptions to that termination? I think there's exceptions when the patient may not be terminated. You have an emergent or acute medical condition or a pregnant patient approaching delivery or some contractual agreement, to avoid allegations of abandonment. These are careful considerations. What thoughts do you have, Myka, about this?
MYKA WHITMAN: I think there should be special consideration for patients that are in an acute phase of care or is following up post-hospitalization or a recent surgery. Those are situations where their follow-up care is vital to their overall health. And this may be a phase within the health care plan and the relationship that you would not want to terminate until you've been able to realize that the patient is stable, or that the patient has indeed sought out an additional relationship with another provider to continue their care.
You wouldn't want to just leave them when they're in the middle of a phase treatment plan. When we think about phase treatment plans, an oncology patient comes to mind. If they're in a phase, outpatient chemotherapy, and they're on the third of the fourth outpatient regimen for treatment, that would be a moment where we would want to really take a significant pause to review what are the risks of terminating this patient-provider relationship at this point. If it poses a high risk to the patients probably not a safe termination decision.
Any terminations that are based on patient's race, their creed, color, national origin, marital status, sex, sexual orientation. If there's any type of perceived bias with that patient, that's when I think you really want to have those deep conversations. Very considerate to ensure that there's not some of bias coming into the decision to terminate that patient relationship.
And then also, if there is a time when the physician is the only available position in a specialty, we've talked about, healthcare deserts becoming more and more common within our industry. And some states, they may only have a provider in one county and the nearby six or seven counties don't have that specialty. So if you're the solo physician that can provide that specific type of specialty care, this would be another consideration for really contemplating is terminating this patient-provider relationship the best decision?
Some difficult choices to make at times, but always want to take into consideration what is the best decision for the patient as well as the provider without putting anybody into undue harm or a risk situation.
JOAN PORCARO: Yes good call outs. And I think it's also important just to remind our listening audience that it really is ultimately the physician's decision. Of course, the care team can play a role and provide that type of feedback with regard to their experiences with the patient. A lot of times when I'm helping our clients, I'll find out that there's been a pattern of behavior, particularly when we think about some acting out behavior that person at the front desk is having a hard time every time the patient comes in or their family is creating challenges.
And when we're thinking about those situations, thinking about how that information is recorded, how it's being carried out so that the entire team knows. I know some clients will actually have the team meetings where they're able to review these situations as a team and figure out future strategies.
And so I know in our upcoming episodes, when we continue on the topic of termination of the physician-patient relationship, we're going to be doing a deeper dive and looking at this from a different perspective as well. But in the meanwhile, before we close off this call, what are some of the first steps practices should take when considering a termination?
MYKA WHITMAN: Great question, Joan. One of the first steps that a provider should take is reviewing the patient's record, discussing the patient visit history with the care team, and working with the leadership to ensure that there are no state law requirements, mandates through the medical board, or any contractual arrangement from the patient's health care plan that may prohibit the termination.
You also want to review any contractual agreements that you have related to the patient's termination. There may be language in the contractual agreements that allow terminations if x, y, and z is noted. However, you do not want to terminate a patient relationship if you're contractually bound to see that patient. And really, the goal is not to just protect the practice, but also to ensure that the patient's discharge is safe for both the physician and the patient.
It is important to note that the ultimate decision whether to terminate the relationship absolutely rests rest with the physician like you mentioned, but other team members should be able to provide supportive documentation and feedback about any past problematic encounters, behaviors, concerns, attempts for follow-up, attempts to reconcile any barriers. You want to ensure that there is supportive documentation in the patient's record that will explain the rationale for wanting to terminate that relationship.
No other team member may terminate the relationship without the direct guidance of the provider. I think that's an important thing to remember as well. And sometimes we get calls from clients where the provider wants to continue the relationship, and the office staff may have more concerns with the behaviors, because again, patients may treat providers differently than they treat the rest of the health care team. And I love that you recommend those team meetings to really discuss as a team some of the past behaviors and concerns transparently together to give everyone the best opportunity to make this difficult decision.
When we look at documentation, this is one of the points that we really stress with our clients. Have all the patient instructions and all of the educational efforts and the reminders and the voice notes or the contractual agreements, have all of those been thoroughly documented in the medical record? Does the documentation include a record of all of their missed or canceled appointments, and does it also include any attempts for the patient follow-up? If you're calling those patients, if you're sending letters, make sure that all of that is documented in the record as well.
Any attempt by the provider or staff to address their concerns or resolve conflicts has that been documented, and how has it been documented? We always want that to be documented in an objective manner. If the existing documentation does not adequately support the rationale for ending the provider-patient relationship, sometimes we advise for the provider to continue care until such time as the record justifies that decision.
Now, of course, this is negated if there are any, threats or actual physical harm. We would not recommend continuing the treatment. But if it's for things like noncompliance or missed appointments and you don't have that documented in the record, this is one time that we may recommend going ahead and continue that relationship until you're able to document more of the behaviors.
JOAN PORCARO: Yes, really good call outs. And I think the thing that we have to remember is a relationship is a story. And we really need to tell the history behind that story. And it's really helpful. When I've been helping different practices, I will go in and I will review that documentation, and then I interview the staff that had encounters with the patient or that particular family to check in with them to find out some of the anecdotal type things. And that's usually where I find that pattern. There is a lot more factual information that I'm not seeing in the record.
And we don't have to get extensive documentation, but we want it to be factual and lacking in any type of opinion. We simply want to state the facts. I recall working with a client many years ago that had been with a patient for 11 years, and the call I got was, we need to terminate. When I did a deeper dive and audit it, basically, did an audit of the history of the relationship, it looked like they just had one bad encounter. But as it turned out, with the interviews, I found out it had never been really a good relationship from the start.
So I also talked to the practices about utilizing strategies like limit setting and some of the other resolution techniques, which we'll get into in future episodes. But again, we're coming to a close here to this particular episode. And I first want to thank you, Myka, for joining us today.
MYKA WHITMAN: Oh, it's been a pleasure. And I look forward to getting into more of the details of this difficult process.
JOAN PORCARO: Oh, indeed it is. And to have a kind of a caring review of some different approaches is always found to be helpful by the practices. And so, in closing, I want to thank our audience and to those who have tuned in to our discussion, and I hope you'll be joining us for future discussions in the coming weeks and months. And again, thank you for listening to our podcast, WTW Vital signs.
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