A 45-year-old woman with a history of atypical chest pain, hypertension and type II diabetes mellitus is being seen by a physician for a new patient visit. She reports that her previous primary care provider had performed some tests to evaluate her chest pain, but she does not know what those tests were, nor the results. In response to a request for release of records, the prior physician writes back that the woman has an outstanding balance owed to his office for the co-pays her insurance would not cover, and that he will not release her records until she makes full payment. What should the woman's new physician do?
Physicians have much to lose when patients do not pay their co-pays or fee-for-service billings and they may be torn about whether to accept a lack of payments, or submit such billings to collection agencies. However, there are anecdotal reports of health practitioners who try to find other ways to coerce patients into paying their bills. The case presented here is such a situation, in which the previous physician is attempting to hold ransom the patient's records until the outstanding bill is paid. However, such an action can have serious negative consequences for both the patient and the physician.
The fiduciary obligation of physicians in the patient-physician relationship is strengthened by the idea that the needs of the patient should take precedence over the needs of the physician. To those physicians who do not believe in this concept as strongly, the notion of leniency toward patients who do not or cannot pay their outstanding bills may not be as strong as that recommended by the AMA ethics code.
Despite the inclination for some physicians to withhold medical services to patients in an attempt to coerce such patients, some boards of medicine have determined that these actions are grounds for sanction. The College has decreed that such actions are unethical and unprofessional.
When transferring the care of a patient to another physician, the original physician has an obligation to transfer the patient's medical record, regardless of whether or not the patient has paid her bills. To do otherwise would be deemed unethical by many authors and may be seen as abandonment. It has been stated that if the physician acts in his own self-interest as opposed to that of the patient, then that physician has breached his contract with both the patient and the society as a whole. These actions can have a negative impact on the care of the patient.
In addition to the ethical consequences of withholding treatment from patients, there may be legal consequences as well. Most of these involve the potential for malpractice claims by patients due to abandonment. However, many states have statutes in which physicians may be fined or even have restrictions on their licenses for refusing to provide other physicians with patients' medical records.
In the above case, the current care provider can attempt to call the previous physician and explain the ethical and legal imperative to release records regardless of the patient's ability to pay the outstanding bills. The physician can also work with the patient to see if a payment plan can be arranged which might satisfy the previous physician's demand for payment of the unpaid bills. Absent these solutions to the dilemma, should the new physician report the previous physician to the state medical board?
The physician in this case finds himself facing an ethical dilemma of choosing between protecting the privacy of the previous physician on the one hand and the safety of the patient on the other. Physicians may fail to report a colleague in this situation due to potential adverse social, financial and legal consequences. Although physicians are considered to have the ethical (and in some states, legal) duty to report an impaired colleague, for example, the social stigmatization of both the impaired physician and the accusing physician may prevent them from doing so.
Whether impaired or merely belligerent, when a physician is acting in a manner that is potentially or actually harmful to patients, it is the responsibility of a physician who finds out about the activity to report it to the appropriate authorities after a discussion with that physician that does not correct the activity in order to protect the patients.
The new physician was obligated to secure this patient's medical records in order to provide the best care. Through our guidance, he approached the physician through an approach that is similar to a patient-centered interview. He first asked the physician his thoughts and feelings about the patient's lack of payment and his response, and then broached the subject of the patient's financial status. He also informed the physician about the potential for legal action (both civil and criminal) for such an action on the part of the physician, and brainstormed with the physician a way that the patient could make a good faith effort to pay the outstanding balance while the physician would agree to send the records. The medical records were finally released to the clinic.