We’ve all been there – the 89 yo with cancer you want to admit for pneumonia who doesn’t want to spend another precious day in the hospital…the NSTEMI that has to sign out AMA to stop his car from getting towed…the stab victim that insists on leaving CCT at 3 AM because Popeye’s closes soon… or the r/out appy who can’t wait for her CT scan because no one else can pick up/take care of her 2 year old son.
This process is becoming more common. In fact, rates of AMA have risen 41% from 1997 to 2011.
To make it worse, patients that sign out AMA do worse: 2.5 times more likely to die in 90 days and grossly elevated re-admission rates. This data is from Canada, which I think is worse, because they all have health care and can see a primary doctor when needed.
During the AMA process, up to 70% of doctors will tell their patients that if they leave AMA, insurance will not pay, and they will get stuck with a large hospital bill. They aren’t being disingenuous; they honestly believe this is the case. Survey after survey shows over 50% of residents and attendings believe this is true…Unfortunately, the data says that it is not!
An article by Schaefer et al found 526 patients admitted to the medicine service left AMA from 2001-2010. Of the 453 insured patients, 18 cases (4%) were not covered by insurance. They do not list the reasons for all 18 rejections, but does describe the three most common reasons were “untimely submission of the bill, confusion about [accurate] patient identity, and extended utilization review”. In this Chicago hospital, 68% of residents and 44% of attendings, believed that insurance companies would not pay for admissions where the patient AMA’d.
A smaller study in the ER in Annals of Emergency Medicine reviewed 104 ER AMA visits and found that all of them were reimbursed by their private insurance companies. Of the 70 physicians polled, 67% believed insurance would not pay for AMA, and 50% had or would tell patients that.
Lastly, this issue actually went to court (Arkansas supreme court in 1990). A mother was admitted for cholecystitis, had surgery, and was told by her doctor she could leave if afebrile for 24 hours. She was, but the covering doctor wanted her to wait for the surgeon to come back from a weekend trip. She signed out AMA and Blue Shield refused to cover it due to an existing clause in her contract. The good news is the Arkansas Supreme Court ruled for the patient. I read the brief and it’s confusing lawyer-speak. Apparently, Blue Shield was violating “reasonable public policy” in denying payment.
In a review of various court cases where the AMA patients sue and win, the case hinges on whether the jury/judge believe that the patient was fully explained and then understood the risks. Some attendings here recommend you have the patient write in the risks on the AMA consent to have extra documentation that they understand the risks (though I didn’t find any studies on this). In short, make sure the patient has a legitimate reason for leaving and clearly understands both the reasons for your plan and the possible risks of leaving.
Have any of you told patients if they sign out then insurance companies won’t pay?
Will you continue to?
What has your experience been?
Wigder et al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Ann Emerg Med. 2010 Apr;55(4):393
Anne Pfuntner, Lauren M. Wier, M.P.H., and Anne Elixhauser, Ph.D. Overview of Hospital Stays in the United States, 2011, statistical brief 166
Fleeter. When a Patient Leaves Against Medical Advice. AAOS now Nov, 2012
Garland et al Rates of readmission and death associated with leaving hospital against medical advice: A population based study. CMAJ. 2013 Oct 1;185(14):1207-14
andygrock
- Resident Editor In Chief of blog.clinicalmonster.com.
- Co-Founder and Co-Director of the ALiEM AIR Executive Board - Check it out here: http://www.aliem.com/aliem-approved-instructional-resources-air-series/
- Resident at Kings County Hospital
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I personally haven’t ever said this to a patient, simply because I wasn’t sure whether or not it was true. I try to keep it to the medical aspect of the decision making and have as intelligent a conversation as possible with the patient about their decision to leave. If they still want to leave I then write into the AMA form as well as their county generated disposition paperwork something along the lines of “risk of death, dying, loss of function, loss of quality of life” and that the patient is aware of all associated risks and absolves me/the hospital of any responsibility associated with leaving. I have no idea how it would stand up in court but its my best attempt to CMA.
Nice review of a common myth. I don’t think its our place to tell a patient whether or not their insurance will cover a visit as generally we don’t know what specific coverage is provided even in non-AMA cases. If a patient asks or has concerns, I would recommend that they contact their insurance company for any questions related to their coverage.