Public Health Law Map - Beta 5 - Medical and Public Health Law Site

With the recent growth of MCOs, many physicians have contracted with insurance
carriers to treat any patient insured by that carrier. This obviates the physician’s right
to refuse to treat. A person who is injured because a physician wrongfully refuses to
accept him or her as a patient may sue the physician based on this contractual
agreement with the insurance company. Unlike traditional physician–patient
relationship law, which is based on the physician–patient dyad, MCO contracts can
create a physician–patient relationship with a class of persons rather than with a
single individual. When a member of this class requests treatment, the physician has
the responsibility to treat that person as an accepted patient.
Closed-panel MCOs are the most restrictive type of health insurance scheme. The
degree of restriction on the patient’s choice of physicians varies among
organizations, but in general, closed HMO patients have a physician assigned to care
for them. The physicians have even less choice of which patients they may treat. In
this situation, the traditional assumption of a freely determined physician–patient
relationship is inapplicable, and the physician’s duty to the patient probably begins
when the patient is assigned as part of the physician’s panel. In preferred provider
organizations (PPOs) and other MCO arrangements in which the patients have a
smaller copayment if they are treated by certain physicians, the choice of physicians
is limited, but unless the list is very short, the patients still perceive that they are
choosing the physician. The physicians’ position is more ambiguous. They may retain
the right to refuse to treat patients of their choosing, but it is more usual that the PPO
contract requires them to treat any PPO patient who presents in the office, subject to
limitations of scheduling and specialty practice.
F. Expectation of Continued Treatment
There is a presumption that treating a patient creates an ongoing physician–patient
relationship. This presumption derives from the traditional relationship between
physicians and their patients. It is questionable how effectively it describes modern
innovations such as ambulatory care centers in shopping malls and contract emergency
room physicians. The extent of the physician’s continuing responsibility to the patient
is predicated on whether the patient has a reasonable expectation of continued
treatment, the nature of the patient’s illness, and whether the physician explicitly
terminates the relationship.
The family doctor is the idealized physician– patient relationship beloved by nostalgia
buffs and television script writers. In this romantic notion of medical practice, these
physicians are intimately acquainted with all the details of their patients’ lives,
payment is never an issue, and the patients have unlimited resources to comply with
the physician’s recommended treatment. Life was never this way. The central problem
for family physicians or general practitioners is to reach an accommodation between
their style of practice and patients’ expectations. This accommodation helps prevent
legal misunderstandings, but its most important goal is preserving trust and mutual
respect between physicians and their patients. How this accommodation is reached
depends on the type of practice each physician is engaged in.
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