Many times over the last 15 years, I have heard physicians and nurses tell patients, “If you decide to leave against medical advice (AMA), your insurance will not pay and you will be liable for your bill.” This seems like a sensible thought, however, it is not true. It is time to discredit this myth and help patients and providers understand AMA better.
The decision to leave AMA can occur for many reasons which are outlined below. However, let us first explore some statistics related to patients leaving AMA.
- Each year, up to 2% of hospitalized patients decide to leave AMA which in 2011 was approximately 500,000 people
- Patients admitted for general medical care and decided to leave AMA were 7 times more likely to need readmission to the hospital in less than a month.
- 78% of patients who left AMA in one study were found to have government insurance (Medicare or Medicaid) or no insurance coverage.
- Zero patients in a study received insurance denials based on their decision to leave AMA.
Why do patients decide to leave AMA? This is a question providers ask themselves whenever faced with this situation. After all, our job is to help those in need of medical attention and patients come to the hospital seeking medical help. This decision is usually somewhat complex and goes deeper than just simply a change of heart. Patients most commonly leave AMA for the following reasons:
- Social or financial issues: This could be fear of a bill they cannot afford, family dynamics involving children or others for which the patient is the caregiver or fear of missing work among many other personal reasons.
- Substance abuse issues: Addiction is what we call a secondary diagnosis and often we struggle to manage the acute problem because there is the underlying illness of addiction. Sometimes that addition is so strong that no matter what is offered to help with the symptoms, patients are unable to physically stand being in the hospital.
- History of leaving AMA
- Not having a primary care physician
In my professional opinion and experience, supported by the literature, it all comes back to learning excellent communication skills and practicing emotional intelligence. Discussions regarding expectations during the hospital stay, any social or financial stressors or barriers, any difficulty with substance abuse or frequent tobacco or alcohol use and an accurate reconciliation of home medications are vitally important to help the care team create a plan to keep the patient comfortable, decrease anxiety and quickly work through the course of treatment assuring a safe transition home. The more that is discussed up front, the more resources can be put into place for efficient and effective care.
For physicians and nurses, when the above discussions take place, practicing active listening skills is very important. I recommend sitting down with the patient. If it is necessary to bring the computer into the room, make sure that it is not between you and the patient. Practice your empathy skills and really try to connect and understand your patients. In other words, peel back the onion layers and understand what is behind the acute diagnosis.
Have you been a patient or family member and experienced leaving AMA? Are you a nurse or physician and have dealt with AMA discharges? I would like to share your story so that we can help one another understand this topic better. Please comment below. Thank you!