Against Medical Advice: Are A M A Scarlet Letters?
A recent discussion on Twitter caught my attention. A physician posted, “Left against medical advice” is not the same as ‘Left to attend sister’s funeral.’ Let’s choose our words better.” This doctor has a point. The choice of words we use to describe patients is not a minor issue. When I trained, if a patient was not taking their medication properly or following care instructions, we called that patient “non-compliant.” Once the patient’s medical record indicated that the patient was “non-compliant,” the patient becomes labeled as one who does not follow instructions.
Non-compliance though suggests a willful decision on the patient’s part to not follow instructions provided to them. But their non-compliance may be totally outside their control. Perhaps their mail order prescription did not arrive as scheduled or the insurance company wanted the physician to go through an onerous multi-day prior authorization process before allowing the medication to be dispensed. Instead, we now refer to “non-adherence,” a less accusatory term.
Does denoting a patient as leaving the hospital against medical advice, also known as leaving AMA, stigmatize the patient? It is certainly possible. But unlike “non-compliant” and “non-adherent,” denoting that a patient left against medical advice has significant financial and quality implications. But before describing those, it is important to address what “against medical advice” means.
Traditionally, the circumstances leading to patients leaving against medical advice are viewed as adversarial, with the patient unhappy with their care and choosing to leave the hospital without being formally discharged by their attending physician. But as the tweet notes, in many circumstances the patient’s decision to leave is motivated by a compelling reason to leave the hospital despite their satisfaction with the care they are receiving, be it the need to attend a funeral, deal with an important financial matter, or even check on a family member or a pet.
Whatever the circumstance, the physician has made a determination that the patient continues to require care that can only safely be provided in the hospital. Hence, if the patient chooses to leave, it would be against the advice of the physician. There was a time that if a patient left against medical advice, they were asked to sign a form and were then simply allowed to leave. Since the physician did not approve their discharge, they were not provided prescriptions or follow up instructions and were left to fend for themselves. It was felt that to do any more for the patient would perhaps signify that the patient was actually stable for discharge, and if there was an adverse event, the physician could be held liable. The mistaken belief was that the AMA form was required, and prescriptions could not be provided.
But as hospital care has become less paternalistic and more collaborative and the significance of social determinants of health were appreciated, physicians realized that many patients who were choosing to leave against medical advice were doing so out of necessity and should still be provided with medications and post-hospital care instructions to give them the best chance of recovery outside the hospital. Even though the physician is writing a discharge order and the patient is being provided with prescriptions, the patient is leaving against the advice of the physician. Hence, this patient can be properly said to be leaving “against medical advice.” The physician should document the discussion about the need for continuing hospital care, the risks of leaving, and the post-hospital care, including the ability to return to the hospital if warranted. Lastly, the physician should document that the patient is indeed leaving despite understanding the risks and that they are advising the patient not to leave.
Why is this important? When a hospital prepares a claim, the hospital indicates the destination of the patient upon discharge, be it to home, to home with home health care, to a nursing facility, to another hospital, and so on. This information is used when the claim is paid, with payment adjustments often made if the patient is discharged to another facility or to home with home care, depending on the length of stay. There is also a way to indicate that the patient left the hospital against medical advice. Contrary to some rumors, if a patient leaves against medical advice, their hospital stay is still covered by all insurers. But this indication does do several important things.
Looking first at Medicare, if a Medicare patient leaves against medical advice on the day of admission or the next day, the admission will be considered an exception to the Two-Midnight Rule. The admission should not be denied if audited as a short stay inpatient admission. More importantly, if a patient leaves against medical advice and returns to any hospital within 30 days and is readmitted, the first admission will be excluded from the Hospital Readmission Reduction Program. The first admission will not be incorporated when calculating the hospital’s readmission penalty for the targeted diagnoses. The readmission also will not be considered when calculating the hospital’s star rating, which includes the all-cause readmission rate.
For other insurers, designating the discharge as against medical advice will affect payment if the patient is subsequently readmitted. The financial effects of this can be profound. Some payers will only pay for a readmission if the patient was admitted to another hospital for their second stay. If the patient returns to the same hospital, some payers will deny the second admission completely while others will allow the hospital to combine the care in both stays onto one claim. One Medicaid plan in the Midwest has a most unusual payment structure for readmissions. If the patient is readmitted to the same hospital, there is no payment for the second admission. If the patient’s readmission is to another hospital, the second admission is paid, but the amount paid to the second hospital is recouped from the first hospital. However, for this plan, if the patient’s claim indicated the patient left against medical advice, both claims are paid in full either way.
The words we use to describe patients do matter. Despite our best intentions, patients can get “labeled” and this can have unintended effects. But when a patient leaves the hospital against medical advice, it is important that the billing staff know the patient was leaving against the advice of the physician, be it confrontational or collegial, so that the discharge status can be properly entered on the claim. As with many issues, a few extra words in the medical record to explain the circumstances can provide the clarity needed for all involved.
Programming Note: Listen to Dr. Ronald Hirsch every Monday on Monitor Mondays, 10-10:30 a.m. Eastern.
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.