Ethics question for discussion

[HokieDO2010]

patient comes in, you decide they have diverticulosis, and want to admit them, but HMO says pt does not meet criteria for admission. You discharge the pt, and they end up dying or something....who is liable?

choices: HMO alone, you as doctor alone, Both HMO and Doc, or Doc but HMO vicariously....

I had this question on a practice test and wondered about the answer...
Whaddaya think SDN?

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[Cynic]

Legally, the doctor is liable/will be held liable. The HMO didn't say you couldn't/shouldn't admit the patient, they just said they wouldn't pay for the admission. Ethics...blah.

 

[DrWBD]

I think Cynic is correct. In real life if such a scenario were to occur you would have to advise the patient that you felt he needed to be admitted, but his managed care plan wouldn't pay and he might be stuck with the bill.

The "HMO denying reimbusement" scenario seems very common on tests these days. While the HMO can be acting ethically (healthcare dollars are limited and they have a right to ration their spending) the physician may not be acting ethically by using their decision in place of his own clinical judgment.

 

[JW08]

patient comes in, you decide they have diverticulosis, and want to admit them, but HMO says pt does not meet criteria for admission. You discharge the pt, and they end up dying or something....who is liable?

choices: HMO alone, you as doctor alone, Both HMO and Doc, or Doc but HMO vicariously....

I had this question on a practice test and wondered about the answer...
Whaddaya think SDN?

I think the hospital administration makes the call if they will continue to treat the patient or discharge them. Doctors are just employees. Its the hospital that collects money before you see a doctor.

 

[DrWBD]

By the way, I think the OP meant "diverticulitis", not "diverticulosis".

 

[scpod]

.... Doctors are just employees....

No. Very few of the doctors you will ever see at the hospital are employees. Even the ones who are cannot hide behind the administration. It's their name on the medical license, not the hopital's name.

 

[group_theory]

The doctor is liable. The patient's family can try to sue the HMO but the standards are very tough and many patients and their families have been unsuccessful in the past in their pursuit of civil actions.

In this case, the doctor recommends admitting the patient to the hospital, despite the HMO's denial. The doctor is also obligated to help with the patient's appeal of the HMO's denial. Failure to appeal the decision (on the doctor's part) may expose potential legal risk to the physician.


To JW08, the payment/billing process for healthcare is very complex. The physician has the final say on admissions and discharges. The hospital cannot discharge a patient without a physician's order. That would be practicing medicine without a license. Payments to hospitals and physicians are also seperate processes. Physicians are paid for each days' visit (and/or procedures) while hospitals are paid per contract (either DRG, or per day, or some other pre-negotiated rates). Hospital administrators may apply pressure on physicians to discharge their patients, but the ultimate responsibility and decision rest with the physician and not hospital administrators. And contrary to popular beliefs, the Chief Medical Officer cannot order an another physician to discharge (or admit) a patient under his/her care.

 

[DO2Be2013]

patient comes in, you decide they have diverticulosis, and want to admit them, but HMO says pt does not meet criteria for admission. You discharge the pt, and they end up dying or something....who is liable?

choices: HMO alone, you as doctor alone, Both HMO and Doc, or Doc but HMO vicariously....

I had this question on a practice test and wondered about the answer...
Whaddaya think SDN?

You advise the pt that your opinion is they should stay. You offer to help them appeal. If they don't want to risk being stuck with a bill, they may choose to leave but you'd better document that it is AMA.

 

[Jamers]

patient comes in, you decide they have diverticulosis, and want to admit them, but HMO says pt does not meet criteria for admission. You discharge the pt, and they end up dying or something....who is liable?

choices: HMO alone, you as doctor alone, Both HMO and Doc, or Doc but HMO vicariously....

I had this question on a practice test and wondered about the answer...
Whaddaya think SDN?

Doctor only. Good luck trying to say that the HMO was liable.