Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?

BACKGROUND: Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases. OBJECTIVE: To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA. DESIGN: Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010. PARTICIPANTS: Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010. MAIN MEASURES: Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible. KEY RESULTS: Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1-5 scale, in which 5 is "always" inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was "so they will reconsider staying in the hospital" (84.8% residents, 66.7% attendings, p = 0.008) CONCLUSIONS: Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Expiratory abdominal rounding in acute dyspnea suggests congestive heart failure.

Patients in acute respiratory distress require rapid assessment of the cause of dyspnea. We have observed that many of those patients who are in congestive heart failure (CHF) exhibit rounding of the abdominal cross-section during expiration. We sought to evaluate the diagnostic utility of this breathing pattern in dyspneic patients presenting to an emergency department. Twenty-six subjects with dyspnea due to a variety of conditions were recruited from the emergency department at Beth Israel Deaconess Medical Center. Subjects ranged in age from 21 to 94 years and 81% were female. We measured variation in the anteroposterior and transverse diameters of the rib cage and abdomen using respiratory magnetometers and determined phase of respiration with a pneumotachometer. Investigators blinded to the subjects' identities and diagnoses interpreted measurements as indicating normal respiratory movement without expiratory abdominal rounding, slight expiratory rounding, or pronounced expiratory rounding. The likely cause of dyspnea was determined from discharge diagnoses in the medical record. Expiratory rounding was observed in 12/14 subjects with CHF and 5/12 subjects without CHF (p = 0.0186), and pronounced expiratory rounding was present in 11/14 patients with CHF and 2/12 patients without CHF (p = 0.0016). Test characteristics for the association of CHF with pronounced expiratory rounding were sensitivity 79%, specificity 83%, and predictive accuracy 81%. In patients with acute respiratory distress, expiratory abdominal rounding suggests CHF as the primary cause of dyspnea; a greater degree of rounding suggests a greater likelihood of CHF. The clinical utility of this diagnostic sign remains to be determined in a prospective study.