Why do patients leave against medical advice? | Hacker News Reader

Why do patients leave against medical advice?

ncbi.nlm.nih.gov

23 pointsluu81 comments

I left on day 4 of 6 combatting a MRSA infection. I left on 12/31 because the hospital could not tell me if my current insurance (COBRA) would cover the bills for days 5/6. Absurd. Turns out I was right in my estimations that the course of IV would suffice and also that the remaining days would not be covered. I feel like I 'survived' the hospital system, not MRSA.

Couldn’t you have enrolled in a plan that would have covered your treatment after the fact? I think you have 30 days to do so after losing coverage. I agree that the current system in the US is insane, but what was your plan originally for when you lost coverage?

GP could be referring to treatment being covered under the prior year deductible or max out of pocket.

I have a friend who was hospitalized on December 30th and released on January 2nd. And that's how they hit their max out of pocket two times over the course of 4 days.

It's an awful edge case. If they'd gotten terrible vertigo a couple days earlier or later, it would have cost them half as much.

doing this on an annual basis is such an obviously inefficient system (on both sides) that you'd think somebody would've developed a basic mathematical approach by now to disrupt the market.

but of course in practice, most US healthcare consumers don't really have an actual choice about who they buy their healthcare from.

Annual basis for what is a lifetime time frame is one of those things that's bonkers the harder you think about it.

I knew a guy. In 2008 his wife's company went under. So lost the health insurance she'd had for 15 years. No COBRA and in 2008 no ACA either. Her gall bladder got infected and they had to put a second mortgage on their house. Both of them had been paying for insurance for 25 years at that point.

Me I didn't have health insurance between 18 and 40 when I started working for a big corp. Two years later racked up $50k in medical bills. Insurance paid almost all of it.

Crazy.

Weird America-only medical bullshit: it costs way more money to have a pregnancy that spans 2 calendar years, than if you keep it all in one year.

> I left on 12/31 because the hospital could not tell me if my current insurance (COBRA) would cover the bills for days 5/6. Absurd.

For future reference, asking the hospital what your insurance covers will always result in a "we don't know" answer because they don't speak for your insurance. They can't risk saying "yes" when they aren't the ones deciding.

In these cases, call the insurance company. The reps deal with coverage questions like this all day long.

This is good advice, but I can just feel the egregious hold times, insufferable IVR (our choices have changed!), and explaining the same thing to 5 different people until you get an answer that winds up being incorrect but good luck proving that in Small Claims because smartphones are very good at preventing you from recording conversations for your own records.

I understand the reasons why we structure our world using adversarial systems but geez, sometimes it really shows.

>"…because smartphones are very good at preventing you from recording conversations for your own records."

If you don't want to deal with the plethora of scummy apps to record call, you can go old-fashion and buy a telephone pickup microphone[1] for $20.

[1] https://www.amazon.com/Olympus-TP-8-Telephone-Pick-up-Microp...

Yes, but the point is that it's insane that your advice is the correct advice. There should be borderline zero "barrier to entry" for knowing what monetary burden you are about to submit to, especially considering the state you are probably in, and the time-sensitive nature of health issues.

> In these cases, call the insurance company.

I did that once, they told me "we don't know because we don't know what the hospital will bill".

So I decided that I don't know if I'll pay..........

As a physician probably my single most feared infection is a MRSA (or any Staph.) bloodstream infection. It’s a sticky bacterium that likes to destroy heart valves and joints. I’m personally a bit of a medical nihilist but antibiotics often work to treat it and I would not be eager to do the n=1 trial of the shortest effective duration.

Bankruptcy may very well do greater collective harm. Pretty horrifying to even have to weigh that variable.

As much as bankruptcy is horrible, it’s does not compare to the immediate harm of a disseminated MRSA infection.

Let’s not be hyperbolic.

I think you’re very fortunate to not have known anyone who has had to make that calculation.

There is no calculation to make. If you have an untreated MRSA infection, you will die. Now whether the treatment can be overly prosecuted is a different question.

You can set a broken bone yourself. You cannot treat MRSA. You do not walk out of a hospital with untreated MRSA AMA.

If the harm is so great to all of society, then surely all of society would ensure that no one ever has to even think about cutting any treatments short.

Or, even if it's just the knowledgeable and responsible medical profession who knows how important that is, then surely that same knowledgeable and responsible medical profession would ensure that no one ever has to think about doing something they claim to care so much about avoiding. Right?

This responsibility to others argument falls dead flat.

I would rather die than lose all my retirement savings and be forced to find a job in my 60s or 70s. No hyperbole at all.

With an untreated MRSA infection, you wouldn't live to your 60' or 70's. No worries.

> It’s a sticky bacterium that likes to destroy heart valves

Do those grow back crooked or something?

I don’t believe they grow back at all.

No they get destroyed leading to hear failure and shock needing surgical replacement if you survive

Adult heart cells (cardiac muscle) don't regenerate. Once they're gone, they're gone.

> I feel like I 'survived' the hospital system, not MRSA.

You survived the insurance system (or rather, despite it).

The hospitals can't tell you what is covered at the time of service, only well post facto (I literally got a call last week about a copay from surgery I had in May 2022). IMHO most of that blame lies with the insurance companies, but the hospitals are complicit.

The more exposure I have to the health insurance system, the more convinced I am that nobody actually knows what they're doing. For all the insight the average action has, the corresponding actor might as well be a computer program that only compiles on Borland Turbo C++ trying to parse a policy expressed in malformed XML edited by an unpaid intern a decade later.

I once got a bill nearly a year after the actual treatment, with a line item that differed only by the description field's whitespace and punctuation from a charge I knew I'd already paid. There was a smaller line item on that bill that I probably hadn't paid, but just through the magic of calling the phone number and sitting through hold, I was told not to pay anything.

American health insurance needs an additional layer of insurance where you pay in monthly and if you get sick a consultant with knowledge of health insurance coverage comes along and works out these things. Clearly you were mentally capable at the time, but many times people just get ripped off due to a combination of lack of understanding, will power or grief. The only other industry I can think of that waits until customers are at their most vulnerable before gouging for maximum profit is loan sharks.

On a similar insurance related note... I needed an emergency appendectomy and was sent home in pain by non-medical staff.

I had gone to an urgent care clinic with abdominal pain. They pressed on my abdomen to see where the pain was and told me to immediately go to the hospital down the street and there would be a CT scan order waiting. At the conclusion of the scan, I was told to go down the hall to the ER for emergency surgery.

At the ER check-in counter, they took my information. My insurance was a PPO for which the hospital was in-network. After 20 minutes on the phone, they told me that my employer (a 6K person public company, not a small company just figuring out benefits) hadn't paid their premium so they would not admit me. I knew the head of HR and called her directly. She said that premium payments are automated and there were no issues. To make sure, she called our contact at the insurance company, and they confirmed everything was good. I told all of this to the front desk staff, and they said there was nothing they could do. They said they would contact the insurance company again the next day and call me if anything had changed.

Looking back, I should have gone straight to another hospital. But I was delirious with pain and went home to rest because I was exhausted and freezing cold from sweating profusely. The next afternoon they called and said it had been cleared up and that I need to get there immediately as it was life threatening. I got to the ER, and they started a series of tests to determine if my appendix had burst (it hadn't!). A doctor came over to review the test results, saw that the CT scan was the previous day, and yelled at me for several minutes about how I risked my life by listening to the front desk staff. I asked if I should have forced my way back to find an empty bed and just jumped into it. He continued to yell at me until a nurse physically pulled him away. I finally had the surgery late that night (with another doctor that was not so agitated), and everything went well from there.

So, I initially left the hospital against medical advice, but at the insistence of non-medical staff. A different situation, but sometimes taking medical advice is not an easy option.

This is so depressing, I’m sorry you went through that.

That's insane. Luckily in the US this can't happen (post 1986) as EDs cannot deny care to anyone under EMTALA.

This was in San Francisco in 2016. Maybe it's not supposed to happen, but it can.

To Europeans, US is like the only place where this constantly happens.

> A doctor came over to review the test results, saw that the CT scan was the previous day, and yelled at me for several minutes about how I risked my life by listening to the front desk staff.

Has he tried yelling at the front desk staff yet? I hope you know his name and contacted him afterwards.

> I asked if I should have forced my way back to find an empty bed and just jumped into it.

I assume that would get you arrested, and maybe even dragged to jail. :S

I've witnessed several people AMA from hospitals.

All of them were not being treated well for pain and even in cases where there were calls for psych staff to help - there was imo below minimal mental / emotional support given.

In a couple of the cases the people were able to find better pain medicine on the street faster than they could even get a doctor to answer a nurses call to deny - and being able to find just one person who would listen or offer any other emotional support was better than what they got paying 10,000$ or whatever it is to stay in a luxurious beeping room.

I'm talking about people with real pain - not a junkie looking for a fix.

I believe these issues have been exasperated since 2019- it appears that most hospital staff is burn out and no longer fit for the job of handling stressed out, hurting people. 2 out of 3 hospitals around here have big signs all over the place stating they have zero tolerance for rude or abusive people.

This policy itself is abused, and it's led to an even worse power dynamic / class war that is making hospitals worse for care, and sending more people to illicit pain management solutions.

small data points. more does not equal all - ymmv.

Anesthesiologist here. Pain sucks. It’s notoriously hard to treat. Hard to measure. And most of our treatments for it have real, often life threatening, side effects.

I get no greater pleasure as a doctor as to when I get someone painfree. Luckily I have some tools, like nerve blocks, which help in certain cases but even that’s limited.

Pain just sucks.

I’m an anecdote, but I deal with chronic pain that is thankfully well-managed at the moment.

When it wasn’t as well-managed my experience was that apathy among medical professionals was the norm and compassion was the exception. I’ve had particularly bad experiences in the ER and I’m reluctant to even go there anymore. There’s a whole performative thing you have to do at the ER to “demonstrate” that you’re not a drug seeker and it’s difficult for me because I am somewhat stoical in my expression of pain.

I don’t know what’s wrong with the medical system that has created such apathy toward pain, but it feels like it goes beyond just concern over drug-seeking. It’s a critical problem.

>I don’t know what’s wrong with the medical system that has created such apathy toward pain

I think it's that they are harassed 24-7 by addicts seeking drugs. A callous forms. If you are the legit rarity then so sorry.

It's a problem with government policy that demonizes addicts and makes drugs hard to get. It's a problem with a pharmaceutical industry that seems to be playing games with supply and manufacturing. It's a problem with a medical industry that maximizes profits by hiring the smallest medical staff possible and running them ragged.

It's a dog's dinner all around. In a better world we'd probably hang the bastards. But realistically, I guess what we need is more black-market drug manufacturers. Basement percocet labs. Backyard opium farms.

"I think it's that they are harassed 24-7 by addicts seeking drugs." - I don't think this is an issue, or is very minor - although maybe it is different in different places?

Perhaps places like portland or frisco are different than around my neck of the woods or are outliers compared to the country as a whole (?) - happy to get actual data.. not sure why anyone would go through the torture of an ER visit for drugs as an addict when you could hold up a piece of trash cardboard for 30 minutes and get enough cash to buy any dope you want within a stones through of any street corner easily these days.

My thinking on this issue is that the 'war on drugs' has had many side effects that are worse than the cure, some thoughts:

Lawsuits that cost big money have been filed and succeeded against pharmacies, individual doctors, clinics, hospitals and such right? (this scares the shit out of the people in charge and makes them force underlings to virtually stop prescribing anything that could cost money via suits)

Criminal charges for all these (doctors, dentists, clinics, hospitals, etc) - and not just charges, but also investigations - harassing staff, demanding paperwork, under cover investigations trying to trick people into making mistakes - ending up on a 'list' - even if you are not doing anything wrong, certain numbers or algorithms from a pharmacy can trigger being looked at -

the threat of having your ability to write pain meds - this could make it so you don't can't do many higher dollar services (think dentist, surgeon) - makes people err on the side of less meds than you may need..

All these places seem to want to punt on the responsibility..

eg - go to ER with pain level 9 for tooth infection - they give you a tylenol tell you to follow up with a dentist or primary care doc -

This war has created situations where pharmacies are blocking meds to patients against doctor's written instructions, doctors worry what pharmacies will do - worry about dea will do - worry what investors will do - worry if they can keep a license to work, if they can stay out of jail, if they can pay student loans and home mortgages -

they worry about many things more than they care for the health and well being of the patient, your family member or whoever.

There is also a class war going on - from what I have seen it's what language a person uses at a ER / clinic / DR - as jnovek mentioned 'There’s a whole performative thing you have to do at the ER to “demonstrate” that you’re not a' - there is a quick breakdown in these situations where a DR or nurse takes offense to language or the patient does not know how to communicate pain and suffering in the flower-y language that doctors are used to -

There are more factors, surely I am not thinking of them all at during this 5 minute reply post.

The extreme torture I have recently witnessed when this type of thing occurred was quite disturbing.

Even if you don't pray, pray that you never end up in an American hospital with extreme pain that does not show up on their cat scans well. imho, ymmv.

I left AMA once because I was fine but the hospital wanted my perfect insurance in Yuma, Arizona where most of the patients are uninsured immigrants.

I understand that they need to money to survive but three weeks was just outrageous.

The shockingly low priority hospitals give to patient sleep might be a factor that the authors missed.

Seriously! When my first child was born, we stayed as long as possible, basically until the nurses more or less kicked us out. There was tons of support, and it was as pleasant an environment as I can easily imagine.

For baby #2, the focus was 100% on getting the nurse and doctor through their appointed tasks. 14 hour old baby is actively nursing? Too bad, hand her over, its time to do the measurements. We got so fed up that we requested early checkout, was told "they'll be over in 5 minutes to do last-minute checkout", and after 45 minutes of waiting, we just left.

Sometimes, I suspect "against medical advice" actually means "expected medical advice that was never actually delivered".

They let you leave without checking out? Our hospital was very tight on security because baby identity verification is a whole thing.

Instead of continuing to wait for the nurse doing their rounds, we went up to the nurse's station, stated our intent to leave, waived off all the "we really think you should stay", then they matched up the ID tags, cut them off, and away we went.

Pro tip for any spouses out there on that first night in the hospital:

Tell the nurses to screw off if baby and mom are doing fine.

We had a similar issue in that they would come around every hour and do 45 minutes of testing. Let mom and baby sleep and eat for a while, they've both been through a lot.

Also, for the first timer's out there: Your normal rhythm of doing something hard and then going to relax and recoup is not how babies work. Like, you go climb a mountain, take a test, have a hard day at work. Then you go home and relax and recharge, right?

That's not how a newborn works. The labor and delivery are the start of the 8-12 week long process of getting the newborn used to a day-night cycle and a feeding cycle. You really don't have any recouping or recharging time for the next 2-3 months. You don't have it after the 2-3 months either, but things get a bit calmer and you'll likely be sleeping more by then though.

I don't want to scare you off parenthood, but let you know that the normal way of things is not how your life is going to go now.

Yes, I have not gone AMA but I have heavily pressed a doc to get me out RIGHT AWAY because I was getting worse in a hospital rather than better. Sleep was the top concern, and my biggest frustration was how nurses and doctors would all chuckle, smile a little, and say "oh, we know, everybody has a hard time with lack of sleep here" like it's some charming quirk of the system. Often these would be like "pill at midnight, vitals check at 2am, labs at 5am, vitals again at 6am." I mean at least lump vitals together with other existing wakeups! Nurses also vary greatly, and the best ones would work out ways to improve sleep a bit and the worst were just unbearable in slavish adherence to schedules in the chart, even when some of them are obviously arbitrary or flexible. (Don't wake me up to give me a scheduled pain pill! If I'm sleeping well, I'm not in pain.)

> Other reported reasons that contributed to a patient deciding to leave the hospital against medical advice include poor customer service, respect, and quality of care. This perception was determined majorly by the cultural background and the healthcare team.

I know a rural guy who was once damn near ready to start a fistfight to get his wife out of the local hospital AMA. He believed they weren't qualified or equipped to actually give her proper care and were basically just stalling with useless treatments. And, at least as she tells the story, he was absolutely fucking right to drive her down the highway to a hospital in the nearest "real" city. I guess word gets around when the only hospital within 25 miles has a habit of falling back on explanations like "it's just heartburn; the next round of antacids will definitely fix it".

This paragraph caught my eye:

> The financial burden is not imposed on the patient only; the healthcare system is also affected by the consequence of leaving against medical advice. Reports have shown that the cost of an average stay was USD 3716.00 for those patients who left as planned. However, patients who left against medical advice and were readmitted had an average bill of USD 10,761.56 for staying 4.7 days in the hospital upon readmission.

This makes me laugh. As if medical care in the USA isn't already ridiculously inflated.

> Perhaps the most effective way to decrease discharge AMA is through changing existing policies and/or implementing new policies. Historically, governmental policies, incentivizing or penalizing, have dramatically driven substantial changes in the medical system. For example, different healthcare policies/programs have led to improved healthcare access in non-urban areas. Another example is the change of practitioner compensation from traditional fee-for-service models to bundled-payment models that resulted in a better quality of patient experience [51]. Therefore, implementing a lower rate of discharge AMA in hospital metrics, for example, will incentivize hospitals to further invest in mitigating discharge AMA.

We absolutely shouldn't penalize people who leave a for-profit business for not getting the service they desire. Also changing to fee-for-service would help people do a cost-benefit on their medical issues. If we are going to live in a capitalism world, then let hospitals compete for your money.

Part of my job I build predictive models to identify individuals at high risk of 'readmission' (it impacts billing, hence why healthcare systems are interested).

Conditional on an individual's history (e.g. do you have diabetes, other comorbidities, etc.), I haven't found much evidence that leaving against Dr advisement matters all that much for predicting readmission.

The number in the GP is conditional on the patient being readmitted, so it's inflated by adverse selection: it doesn't include all the zeros where the patient recovered, but it does include all of the cases where something went wrong and they needed more/different treatment.

Yep, looks like classic “survivorship bias”: https://en.m.wikipedia.org/wiki/Survivorship_bias

> I haven't found much evidence that leaving against Dr advisement matters all that much for predicting readmission

maybe cos they're dead

So although tongue-in-cheek, it is an interesting question when dealing with medical records data (in particular I deal with insurance claims data in the US).

So to be clear, I know the person is alive when discharged (there is a code for death, as well as to hospice for example, in which you don't want to look at readmission either).

So a scenario in which someone is discharged, has a follow up heart attack, goes to ER and dies I would observe. The case the person dies and does not go to the hospital though I would not observe (no follow up insurance claim).

The latter scenario certainly happens -- how often it happens and how much it would bias my estimate in this case I am not sure.

> This makes me laugh. As if medical care in the USA isn't already ridiculously inflated.

Honestly this is an area where I'd invite Elon Musk to come in and disrupt. In the same way that he disrupted space travel and electric vehicles in part by asking, "do we need to do everything in the expected high cost manner"? Question if you need certain things to be at certain medical grade for everything. I get that staff is expensive, but everything else seems WAY overpriced.

I think neurolink is a good example of why we don't need Elon disrupting health care

Oh, no. Musk can do nothing good for social systems. His models of social systems are oversimplified, and his methods are not for social systems. You can fail an orbital launch just to see how it will go wrong, to learn things. But such experiments on human subjects and societies are frown upon at very least. And with medical care there are people lives at stake. Thousands or maybe hundreds of thousands annually. You don't want to disrupt this system, to reform gently maybe, but without any disruptions.

Your prosthesis will be a wooden leg and treatment for pain will be some high-tech irrevestible lobotomy

I don't think that's what they're proposing. The penalty would be to the hospital for having a high rate of AMA discharges.

Which is exactly what Medicare does to improve outcomes. They apply penalties to the payouts in bad outcomes

TIL Ishikawa fishbone root cause analysis

https://en.wikipedia.org/wiki/Ishikawa_diagram

Of course I've seen them before but was struck by the interesting name.

My father went through a crazy amount of medical care in a few short years. He checked himself out AMA twice. Once because the provider was an idiot and making him sicker. Another time so he could die at home instead of in the hospital where they couldn't really help him anyway.

Hospital - where they’ll wake you up to give you a sleeping pill.

My dad had a heart-related scare, but we left the hospital after waiting 10 hours and not being seen (we were checked in an triaged, but that was it). Thank goodness I had prepared multiple meals + brought water but we did not expect that long of a wait, especially for something heart related.

After all that time, it just felt less risky to go home and get some baby aspirin. They made us sign a waiver as we left.

> They made us sign a waiver as we left.

Could you have refused?

Maybe? We were tired and just wanted to go so we didn't fight them on it.

I mean you could just… go. Like get up and walk out of the room. Unless you’re under a psychiatric hold or other such specialized circumstances, they have no legal authority to keep you there. It’d be holding you against your will, and a criminal action by the hospital. You have the right to just get up and walk out without signing a damn thing, though they may try to tell you otherwise.

In retrospect we probably should have just done that.

people want to be back in their own homes. i was in hospital a year ago (nhs, fractured ankle) and the guys in the whole ward i was on were literally desperate to get out of the place (which wasn't horrible, and i think the nhs is brilliant). it took me probably an extra week to get discharged that it needn't have done. but there is a lot of arse-covering going on.

> people want to be back in their own homes

Seriously why are "bad food" and "noisy nurses" not on the list of reasons? People want to eat and sleep and if they feel like their acute medical problem is manageable I can see why they'd want to leave.

well, i sort of thought that those were implied by what i said (we all wanted to get away from the whole hospital vibe). but i have to say that all of the nurses in my extended stay were great, and not so noisy. a friend was working doing the catering there, and she said they did their best with limited resources - i had some ok meals.

as i say, i really appreciate the nhs, tho perhaps not the bureaucracy.

Been in NHS hospital a few years ago, food was fine, nurses were great (if horribly overworked).

This. I was hospitalized for 12 days a couple months ago. At the end, I was going to leave if I wasn't discharged by a certain day because I couldn't take the food anymore. Fortunately, it didn't come to that but, my god, the food was horrible. And I'm not a fussy eater. I did my best to work with what I had, and had friends bring in food from the outside (I wasn't on any restrictions) but I finally reached the end of my rope.

ah, you should have spent 5 years at a british boarding school - after that, you will be able to eat and enjoy almost anything! the only things i really draw the line at are whelks and tripe. neither of which are normal hospital food.

Why didn’t they just leave? They’re not prisoners.

no, they are not. but if you want to get continuing support, you need to go along with what the medics and ancillary staff are saying. for example, physiotherapy.

My five-hour Atrial fibrillation didn't convert until I left the hospital ER. The hospital was so stressful with constant beeps, patients moaning or crying, staff disappearing, that it was obviously keeping my pulse high despite meds.

I honestly felt like my job was to comfort the harried staff.

When I got my meds the next day, they only cost $0 because I used up my entire $6k deductible that night.

During my hospitalization for thyroid storm/afib, they had the heart monitor alarm set to too low a heart rate for what I had. It was loudly beeping constantly. I kept asking the nurses to fix it but was given various excuses. Finally I unplugged my connection and told staff that I wasn't going to let them plug me back in until the alarm was fixed. They finally adjusted it. I watched how they did it, though. So the next time someone set the alarm too low, I waited until the coast was clear and I set it back. Good nights of sleep were back!

When I wanted to get my teeth straightened the first doctor suggested pulling two teeth to make room. I walked out quickly. The second doctor confirmed the suspicion that this would have been completely unnecessary.

My ~18 month old son is medically complex, and his pediatricians send him to the ER basically every other week. ER docs run a bunch of tests, shrug and say LGTM and send us home. The hospital is an hour away, and they never get any closer to figuring out what the problem is (just follow up with X specialist in Y months). My wife and I are sick of it, but we’re worried that if we don’t take him in when they tell us to that CPS might get involved. So off we go, wash rinse repeat.

All of that to say, if someone wants to leave early, I get it.

I don't know what medically complex means exactly but it sounds like you are being taken advantage of. Can you find a new set of pediatricians and see if they put you through the same ringer? That sounds horrendously expensive.

Because you realize the Drs. are proxies for hospitals and err on the side of hospital stay despite quality of life balance.

They follow guardrails closely aligned with insurance and liability too. Unfortunately.

Because the hospital is clearly an incredibly unhealthy place to be. A nightmare.

It's Walmart. Or a meat factory. Or a jiffy-lube. The cashier wants to stick a needle in you. The surgeon forgot to install your oil-filter.

And don't get me started on the staff. Most of the doctors I meet are just children with technical training. Mentally stunted. Sleep deprived. These are not the people you want fiddling with your health, or anything or anybody that you care about.

I was recovering from insomnia and slipped on a spilled drink in the night. I had thirteen stitches from my head hitting a table. When I came to, I had an orderly follow me down the hall, trying to convince me to stay as I might have a concussion. I called a cab (pre-Uber, at least for me) and went home. I just hate hospitals.

Was it stupid? Probably. Though I’d probably do it again.

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