I want to share a little bit of back story before I start the actual article. We just had our 5th child. It was a natural birth at a local hospital. Our first birth was a water birth in a birthing center, and we went home three hours after the birth. Our other three were all natural in-hospital births, where the hospital required us to stay for 24 hours for observation after the birth, and my wife was sick of this. We made a birth plan specifying that we wanted to leave 12 hours after the birth, and while we forgot it at home, we made our plans very clear to the hospital staff. Our nurse, our midwife, and the pediatrician all accepted our decision, though some of them did not agree with it. The nurse, however, informed the billing person for the hospital, who came in and informed my wife that if we left against medical advice (the hospital's 24 hour policy required the pediatrician to write the discharge for the baby as "against medical advice" if we left before 24 hours), Medicaid would not pay for the services provided for the baby, and we would have to pay out of pocket. The midwife had told us something different, so I went home and did some research, while my wife tried to contact Medicaid by phone. Eventually, she reached Medicaid who told her that they had no such policy and could only find a reference stating that if we brought the baby back before the 24 hours were up, we might be charged for services for the new visit that did not qualify as medically necessary. Before that, however, my research at home revealed a rats nests around the billing lady's claim. First, her claim was completely and absolutely false. Second, most hospitals tell their patients this lie (though, hospital staff rarely knows the truth to begin with) and not just those insured through Medicaid. I found three research papers from three different studies about this problem. None of them found any insurers in the US with such a policy. Anyhow, we left about 13 hours after the birth, and we informed the nurse that the claims were false and asked her to forward that on to the billing lady (the baby had no issues within those last 11 hours, though, the hospital staff had already determined she was perfectly healthy and the probability of problems was extremely low).
It should be obvious that poor people in the US face regular discrimination. It is awfully hard to get hired for a job, even a really poor job, without nice clothing to wear to the interview (in fact, at least one US charity loans suits to poor job applicants to wear to interviews). Many Medicaid, Food Stamp, and WIC office employees treat clients as inferiors. Often, schools in poorer areas of towns and cities get sub-par teachers, while the other schools get the more skilled ones. Middle and upper class people often look down on poor people and treat them as inferiors, and sometimes poor people even treat each other more poorly than those with more wealth. Many Americans assume poor people are lazy. This problem is so prevalent that comments from the few people that really are freeloading on government welfare often reflect badly on anyone who is receiving government welfare for any reason. There is one place where this discrimination against the poor is especially repugnant, not to mention of questionable legality.
Most hospital employees in the US will tell patients that if they leave before their treatment is complete (known as leaving "against medical advice" or AMA), their insurance will not pay for it. Because most patients leaving AMA are Medicaid patients, and because more wealthy patients can afford the costs better, this affects poor people far more than anyone else. At least three studies have been done on this subject in the last three years, and none of these studies have found any insurance provider in the US with such a policy (some insurers actually laughed at the researchers for even asking). Medicaid also has no such policy. Now, in most cases, the hospital employees are not deliberately lying (though, hospitals do stand to benefit from patients staying "for observation" longer than is strictly necessary). This is a common misconception among hospital employees, and it is presumably perpetuated as interns are taught this lie by regular employees. This problem is not just bad for patients, it is also bad for insurers and potentially very bad for hospitals.
Because this problem affects primarily the poor, it is a clear case of discrimination against the poor. As such, it is rather appalling. It is also dangerous and perhaps even illegal. This may be one reason that medical costs in the US are so high. The biggest reasons people leave a hospital AMA are poor treatment or lack of additional time after treatment is complete. Often, Medicaid patients have long waits to see a doctor, when their conditions are not critical. Eventually, they get fed up with waiting, and they sometimes leave against medical advice. The second, and more nefarious problem is when a patient has completed treatment, but the hospital either wants to observe the patient for an extra day or more, or the patient has to wait a long time for the doctor to do a final review and sign discharge papers. In both cases, the hospital may charge more money to Medicaid, another insurer, or the patient, for the longer stay. In the second case, however, it is possible that the long waits are actually deliberate abuse of the system, designed to allow the hospital to charge more for the visit by keeping the patient there longer. Either way, forcing patients to wait so long that they consider leaving without getting full treatment is dangerous to the health of the patient. Telling the patient that insurance will not pay if they leave early, however, may be more dangerous to the hospital than the patient.
Most hospitals require patients to sign a release before leaving AMA, to reduce liability for any problems that might have been prevented had the patient received full treatment. Patients leaving AMA is considered a big problem in the US right now, especially among Medicaid patients (males patients are also more likely to do this). Concerned hospital workers may be tempted to lie to patients to convince them to stay and complete treatment. This carries two very dangerous consequences. If found out, these lies will cause patients to distrust doctors, and this is already a big enough problem in the US; we really do not need to add to it. Lying to patients may cause them to look for alternatives to normal medical treatment that might be dangerous or at least allow serious conditions to go untreated. This is not in the best interest of the patients, and as such, it qualifies as a violation of the oath taken by nearly all medical practitioners in the US to avoid harming patients. The second consequence is worse, at least for the hospital. Medical patients have legally protected rights in the US, and one of those rights is to refuse treatment. Any medical patient in the US may choose to leave a hospital at any time, without legal penalty, and if the hospital attempts to hold them against their will, the hospital is breaking the law. This is a very serious offense. Lying to a patient to manipulate them into forgoing this right, when they would otherwise have chosen to exercise it is a violation of this right. Telling a patient that there will be severe financial penalties (for people on Medicaid, nearly any hospital bill is severe) is essentially forcing the patient to make a choice under duress. Decisions made under duress are not legally binding. If the patient has informed a hospital employee of an intent to leave AMA, and the hospital uses this lie to convince the patient to stay, the patient's original decision is still in force (because the overriding decision was made under duress), and by keeping the patient, the hospital is both holding the patient against his or her will (this is illegal by itself) as well as violating the rights of the patient.
There are several better ways to treat this kind of situation. First, financial employees in hospitals should determine policy for specific insurance providers before any employee is allowed to suggest to a patient that penalties might exist. Since most insurance companies have no such penalties, there is no point discussing them without asking the companies first. Second, instead of trying to scare patients to stay by lying to them, it should be far more effective to inform them of the actual medical consequences of leaving AMA. Even Medicaid patients are not stupid. If they still want to leave, fully informed of the potential consequences, then it is their legal right to do so. At that point, they have chosen to own the consequences, and nobody has any right to force them to stay.
This problem is dangerous to both patients and hospitals. Employees need to be educated properly so that they do not inadvertently do or say things that could get the hospital in trouble. Violations of patient rights can incur heavy fines, and multiple instances can get hospitals shut down. Given how prevalent this problem is in the US, there have probably been enough of this kind of patient rights violations at most US hospitals to get them shut down. Further, this kind of discrimination against the poor needs to stop. Most poor people may not have the research skills to ever discover the lie they have been fed, but this does not absolve hospital employees of their responsibility to treat patients well and honestly. If nothing else, more care should be taken to treat the poor fairly and legally, because they have a disadvantage.
Following are the studies on this problem:
The University of Chicago Medicine
http://www.uchospitals.edu/news/2012/20120203-billing.html
PubMed.gov, Journal of General Internal Medicine
http://www.ncbi.nlm.nih.gov/pubmed/22331399
Annals of Emergency Medicine, An International Journal
http://www.annemergmed.com/article/S0196-0644%2809%2901798-3/fulltext
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