When the Doctor-patient Relationship Has to End

When physicians encounter patients who routinely don’t pay their bills or are extremely difficult to work with, they may think about dismissing these patients from their panel. This is not an easy decision. Physicians have an ethical duty to promote continuity of patient care, and may fear being accused of patient abandonment.
The medical profession is increasingly, and appropriately, tuned into the factors that can make self-care and appointment adherence challenging for patients. Sometimes physicians may continue to work with problematic patients, even to the detriment of their own well-being. In certain circumstances, however, physicians can reasonably terminate a patient relationship.
Typically, a physician’s relationship with a patient ends for one of several reasons: the patient seems unable to follow the treatment plan and care recommendations, the patient is verbally or physically abusive, the patient continuously does not pay their bill, or the patient repeatedly misses appointments. Patient-provider relationships cannot be legally terminated for discriminatory factors, such as race, ethnicity, gender, disability, age, religion, or sexual orientation.
Physicians considering the termination of a patient have several factors to weigh. Increasing recognition of the social determinants of health has provided insight into why patients may not make their appointments or follow treatment recommendations. Barriers outside patients’ control may include certain disabilities or illnesses, reactions to medications, literacy or language issues, financial hardship, social challenges (such as domestic abuse), and logistical or environmental factors (for example, inadequate transportation or housing). For this reason, the term ‘noncompliant patient’ has fallen out of use. Contemporary practice models and standards of care emphasize respect for the ‘whole patient,’ shared medical decision making and the patient-centered medical home as a means of lowering or navigating some of the barriers.
When considering terminating a patient-physician relationship, it is good practice to allow patients an opportunity to rectify the situation. Physicians cannot terminate a relationship with a patient because they haven’t paid a bill, for example — but if the patient continues to receive care and not pay for it, the practice staff should attempt to work out a payment plan with the patient. If the patient continues not to pay, the practice can consider terminating the relationship.
To avoid a claim of patient abandonment, once a physician has identified a reason for termination, they should consider these steps:
Review contracts and communicate with health plans. It’s important for physicians to review their health-plan contracts, especially for the patient in question, and check for clauses regarding the termination of a patient-physician relationship. Alternatively, a physician can contact the patient’s health plan and discuss next steps to ensure the termination is handled according to the terms of the contract.
Provide written notice. A physician should send a written notice to the patient, preferably by certified mail with a return receipt requested. This provides evidence that they communicated the end of the relationship with the patient. The notice should include:
• A brief explanation for ending the relationship (documented in the patient record);
• An agreement to continue to provide treatment for a reasonable period of time to allow a patient to secure care from another person;
• The date the termination will be effective; typically, 30 days is sufficient, but it may need to be extended based on the patient’s condition, payer contract, or access of care;
• Advice that the patient contact their health plan for a list of alternative providers within their network; and
• An offer to transfer records to a newly designated physician upon signed patient authorization to do so.
Communicate with the entire staff. A physician should inform the entire practice staff of the end of a relationship with a patient to avoid accidentally re-establishing that relationship.