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Considering signing out AMA after wife delivers – am I crazy??

Home Personal Finance and Budgeting Considering signing out AMA after wife delivers – am I crazy??

  • Avatar Tim 
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    1) “Imagine the financial benefit to our healthcare system as a whole if we could only take the legal risk out of practicing medicine and do what makes sense.”
    2) “In regards to the original post – My whole purpose was basically to get constructive advice from financial and medical experts on whether or not there is any risk to leaving and I have had great advice (on both sides).

    IMHO no financial advice was sought in any form or fashion.
    IMHO no medical advice was sought in any form or fashion.

    Yes there is risk leaving AMA. Given your wife’s desires, you might push the right buttons to shorten a three day stay.

    Thank you for the illustration.

    #178122 Reply
    Avatar trebizond 
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    LOL, if you had to post on a forum asking whether signing out against medical advice from a hospital after your wife gives birth is a good idea to save money, the help you need is not from a financial forum. you get no sympathy from fatlittlepig. you are a highly paid individual, you chose the type of insurance to purchase. you are not a single mother with catastrophic insurance living paycheck to paycheck who cannot afford something (even then the single mother would do what’s best for their child, so in a way they have more sense than you do)

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    I have already decided to stay in the hospital (more to avoid the inconveniences of deviating from normal protocol than anything else) but I still feel like your post deserves a response for any future reader in a similar situation.

    Assuming you’re a physician I am sure that you understand that leaving against medical advice doesn’t always mean the same thing.  A 45 yo father of 2 with severe crushing substernal chest pain and ST elevation in V1-V4 who leaves because he doesn’t like needles is different than a 90 year old neuro intact cancer patient on blood thinners who fell and hit her head and leaves after her initial head CT is negative to be home with friends and loved ones.  Our hospital protocol wants her to stay a night in obs to rule out delayed intracranial hemorrhage.  In the first case the patient is being irrational and his life is in danger.  In the second case, the only reason I want her to stay overnight is so she can be monitored for a sign of worsening status.  This could be done at home just as easily as in a hospital but because I cannot be 100 percent certain that the patients family will bring her back if things are changing and because our hospital protocol recommends keeping her I have to have her sign out AMA to protect myself in the event of an adverse event.

    I discharge patients AMA on a near nightly basis and there are many times when I would be making the same decision if I were the patient.  You know as well as me that a lot of our protocols are to protect ourselves from legal consequence and offer little if any benefit to patients especially if the patients were in a setting where we could guarantee they were being appropriately monitored by competent individuals.   Many of these patients are completely reasonable and I tell them that I am only making them sign the AMA form to protect myself and that as long as they understand the risks of leaving AMA they can do as they please.  I tend to be quite supportive of their decision.  In the situation of the patient being accompanied by a physician or other medical trained professional I would have even less reserve.

    If I were to leave “AMA” from an OB floor after a safe delivery with a healthy mom and baby I would definitely fall in to the “reasonable patient” category.  Sure, the hospital would prefer for me to stay so we can get our post OB education about car seats and breast feeding for the third time and be congratulated by the smiling med student the next morning who tells us our baby is beautiful. The nurses would think I was insane because, well, “this is how we do things here so it has to be done this way.”  But mostly this protocol is to protect the hospital.  But from who? The first time parent who goes home, lays their newborn on their belly and falls asleep for the rest of the night.  The other purpose of the protocol: to streamline the post-partum process.  Make sure the kid gets his hearing and bilirubin checked because who knows if we can trust parents to take the responsibility to do this on their own after discharge.  Make sure mom isn’t hemorrhaging from her retained products because we don’t know if she will come back or recognize that her bleeding is heavier than it should be.

    Sure my child might have a 6 hour delay in diagnosis of her inborn error of metabolism but symptoms of that illness wouldn’t have even been evident for 6 months anyway.  Sure she might develop difficulty breathing or feeding or not pass meconium.  I would take her right back to the hospital and yes, I know, I would pay the deductible ?

    Imagine the financial benefit to our healthcare system as a whole if we could only take the legal risk out of practicing medicine and do what makes sense.

    In regards to your insurance comment – I’m kind of at a loss, please re-read what I have said about insurance previously, I feel like it should be evident by now that I made the right call with what type of insurance to get.

    In regards to the original post – My whole purpose was basically to get constructive advice from financial and medical experts on whether or not there is any risk to leaving and I have had great advice (on both sides).  It has mostly made me even more comfortable with the medical aspect of leaving early but has helped me to understand that there is not likely going to be much of a financial benefit, especially with considering the inconvenience of doing so and the fact that I am well paid and can easily make up for the financial burden that it would cause.

    When you say things to imply that this is not rational and I need help from some other forum, it seems a little discordant from the rest of the experts here who have offered constructive advice on both sides of the argument.

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    LOL, sorry pal, your examples don’t apply here since the patient is not yourself but a child (a baby at that) and your motivations are to save yourself money (something that as a physician you have enough of). i would quit trying to justify something that is not justifiable.

    FLP

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    I usually despise FLP’s posts, which are smug and self-congratulatory. His record on this thread is a notable exception, some much needed truth and honesty.

    #178141 Reply
    Avatar MFM DOC 
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    To your second point, that is exactly what we did not experience. Our post partum experience makes me sympathetic to the OP. 

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    In my years of OB this was a consistent pattern.  The complaints were generated from the postpartum care not L&D.

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    110%.

    We felt like we had gone from one of the most well-run units we had seen to what frankly seemed like a different hospital.

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    Currently working at a large university hospital…I asked the residents a rhetorical question during sign-out last week when the ball had been dropped on the post-partum unit – “what’s the best thing about the post-partum unit?”

    I got some confused looks.  My reply – “it’s close to a hospital”

    This seems to be a universal truth no matter where you are.

     

    Wife delivered baby #1 and #2 in a different country, left at 7 hours and 4 hours postpartum (respectively).  Delivered babies #3 and #4 during my OB residency, wanted to stay the entire 2 days… sleeping and resting while the kids were in the nursery 🙂  She feels a baby-friendly hospital and having the infants room-in is a travesty, robbing new mothers of much needed rest – I kid you not.

    I’ve been told by pediatricians (but have not confirmed for myself) that some of the genetic tests (inborn errors of metabolism, etc) become more accurate at 3-5 days of life or so.  I think the earliest a PKU test can be done is 24 hours.  Babies #1 and #2 were tested at 3-4 days of life as per protocol in a country with socialized medicine.

    Good discussion all around.  Best of luck on whatever you decide and congratulations on adding another bundle of joy to your family…

    #178144 Reply
    Liked by Kamban, hatton1, MPMD
    Avatar MSooner 
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    FWIW, I left as soon as possible after the birth of all 3 of my children. They were all born in the early AM hours, so we stayed a night and left the next morning for a total of a 24-36 hours stay. I let my providers know that I wanted to be discharged early and it was never an issue–they did a pretty good job of making sure all the “necessary” stuff happened before we were discharged (hearing tests, vaccinations, etc.) We even got the “celebratory meal” a night early at the last hospital, ha. I definitely note these were uncomplicated births with nothing too major going on with me or the babies.

    That being said, I had high deductible plans for my last two and leaving a night early didn’t save me anything. They flat out told me it was the same price when I said I wanted to be discharged early. For me it was more about just getting home because one sleepless night in the hospital was enough!

    I was kind of under the impression once that baby hits the doctor’s hands, their separate bill starts racking up?

    In the spirit of trying to limit the cost of births, I totally understand, though! My due date for #4 was changed from June 25 to July 2nd after the dating ultrasound. My husband didn’t understand why I was getting all worked up about it in the exam room after until I said, “You start fellowship July 1st under a new insurance plan! And your old plan guarantees a $500 baby! And I don’t want to deal with two insurance companies duking it out!!” I was assured I could have an induction if needed after that 😉

    #178178 Reply
    Avatar diagtech 
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    You are not crazy. In England, a queen-to-be, Kate Middleton, was allowed to do the exact thing you are considering. She left the hospital several hours after each (uncomplicated) birth. This was ROYAL family, and still it was ok.

    #178146 Reply
    Liked by RocDoc
    Rogue Dad, M.D. Rogue Dad, M.D. 
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    Newborn screens are generally done after 24 hours of life.  Doing 2 of them, separated by a few days (usually #2 done in PMD office during one of the first couple checkups) is common.

    If we presume the baby and mother are healthy in the first 12 hours, then not much is going to be done for the child besides nursing assessments/assistance.  If the family has lots of help at home, they may not need that.  I’m pretty sure our third child (my wife’s second VBAC) they had a ~24 hour stay.  Being in the hospital with a HEALTHY newborn is awful — only thing worse is being there with a sick one.

    As a pediatrician, I do think the baby needs several hours in the hospital post-partum for observation before going home.  Assuming mom is doing great and no complications and baby is breathing well, drinking some, etc then the “harm” in leaving is having a complication develop at home.  Some of those can develop on day 1-2 when you may still be in the hospital, and some develop later.  Having a couple good pediatrician checkups is reassuring, but if they can happen outpatient in the same timeframe then you may not be missing any needed medical care.

    I think people take issue with the financial motivation more than the medical issues here.  I’m someone who is fairly frugal and get myself in hot water w/my wife over it, and I did take pause at the idea of trying to save $ in this particular instance.  My wife would excoriate me for suggesting this to her, as our first baby was an unplanned C-section and required a Level II NICU stay for a sepsis eval, and it made me paranoid enough that 1 night in the hospital is fine with me anyway.

    I think trying to sign out AMA wouldn’t even work the way you want it to work — that baby is a patient the moment s/he comes out, so unless you literally snatch the baby and run out of the hospital when the cord is cut, that baby is going to get registered and will thus have some hospital charges.  You are not going to dodge the bills to the extent you hope, so the marginal cost savings goes down quickly.  The OB charges may be bundled, but the baby gets their own separate charges, and you likely will get one billed for a full day even if you leave when the baby is 6 hours old.

    If you want to be home for the sake of family comfort, then pursue it from that angle.  But I think it’s going to be hard to save a ton of $ by leaving quickly.

    Also as a reference, we had our last child while on my HDHP.  However we have a combined family deductible, not separate ones per individual.  And our overall deductible I think was $3000 at the time, so not that terrible, so I wasn’t financially motivated to try to leave early.

    But actually being there and sleeping on that shitty bed and trying to change diapers while the baby was in that damn little cart was awful — that’s the best motivation to get home.

    http://www.RogueDadMD.com

    An alt-brown look at medicine, money, faith, and family

    #178222 Reply
    Avatar Tim 
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    @diagtech,
    “This was ROYAL family, and still it was ok.”
    How would a physician know? Probably because he/she were told to be ready at 5am to be on “in-house call” for the next 3 days. Provide the “desired” exam times to the “Royal Physician “ who in turn submits the requests to the “future King” who asks the “Queen” who is checking the three onsite ambulances that have been authorized by the Minister of Health. Standard socialized medicine. Doctors work where they are assigned.
    I am sure Kate scheduled everything herself.
    Everyone in England is on the Royal plan!

    #178229 Reply
    MPMD MPMD 
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    Most interesting thread since the Mayo/CNN one if you ask me.

    Lots of vigorous disagreement with mostly cordial responses.

    I still think the OP is being treated unfairly by his critics and being straw-manned rather than steel-manned. When people ask about expense ratios or renting a cheaper apartment no one responds to them with “you are a doctor, just work extra shifts.” I am totally sympathetic to his position and I also think he’s done a good job of not taking the bait on some of the more over-the-top responses.

    It does kind of seem like this horse has been beaten and now died.

    I appreciate the earlier post about the urban legend of AMA leading to lack of insurance payment. This is so widespread. If nothing else I can’t imagine it would ever hold up in court especially if you think about it from the position of people who leave inpatient units AMA b/c of actual or perceived neglect by providers.

    #178236 Reply
    Avatar Tim 
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    MPMD,
    Is Medicare included in your definition of an insurance plan? Transport between hospitals requires physician approval. The only way back into coverage is through the ED. AMA for neglect vs personal choice are two different situations. I don’t know the “old wives tale” because I wasn’t in your med school. I do know Medicare declined to cover a transfer based upon a patient preference.
    With or without insurance a Dad’s responsibility is for the health and safety of the mother and child.
    There was a commingling of cheaper DIY.
    Qualifications and contingency plans and the “attitude “ or “reasonable” or “sufficient” care is a personal and medical discussion. Decide on the best plan as a doctor.
    Then figure out how to pay for it. That’s not AMA.
    As a physician, what protocols should be eliminated?
    I am hearing, a lot are only liability protection not fully supported by the physicians. He raises valid points of view as a physician. Deserves discussion and conflict.
    As a Dad, he is going to checkout when Doc says “you are good to go”. Might even be sooner than later.

    #178243 Reply
    Avatar Kamban 
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    I feel that if the OP had said early but with the consent of the treating physicians some of the controversy might not be there.

    Saving money is always a good thing if you are endangering the life of the newborn or the mother. But so far in the 6 pages I have not seen any evidence that leaving soon after the birth would save anything substantial. The OP is an ER physician and $3K in the life of a baby is a small amount. And if the deductible would anyway have been met for the baby over the course of 2019 with numerous well baby check ups, vaccinations and other illness that require visits.

    Leaving because staying in the hospital is not to the liking of your wife is a good reason – but that is not a financial one.

    #178250 Reply
    Liked by Tim
    Rogue Dad, M.D. Rogue Dad, M.D. 
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    @kamban — well child checks and vaccines are covered free of charge due to Obamacare. I don’t believe that provision has been gutted yet. Even on the HDHP the baby should have all those visits for free.

    http://www.RogueDadMD.com

    An alt-brown look at medicine, money, faith, and family

    #178260 Reply
    Avatar Western wolf 
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    Quick update for anyone still interested/following: I called the hospital billing department today – apparently it is not an option for me to develop some kind of an all cash agreement rather than using insurance.  According to the person I spoke with it is a state law that bills must go to insurance companies if a patient has insurance.

    Overall, the giant majority of people sharing their advice seem to think that staying 2 nights vs leaving instantly after the birth would not dramatically change the pricing of the admission.  After looking in to this further (and actually pulling all of my bills from the last delivery) this seems to be 100 percent correct.  I doubt that I would have any change in price for overall care if I were to leave early vs staying.

    From a medical standpoint it sure is easier just to follow pre-established clincial pathways.  Even if they may be over the top for my wife and baby’s specific needs.  Whatever, if the hospital is going to charge me the same either way I may as well just accept that I’m going to pay.  As many of you have said, it’s just a couple of shifts in the long run.

    Thanks so much everyone ( @rouge Dad, M.D. @mpmd @msooner @mfm Doc @Drop it into MD @SLC OB @squirrel and more)for your constructive and extremely thoughtful help.  I’m blown away by the amount of time many of you must have spent writing lengthy responses to help a stranger on the internet.  I truly don’t feel worthy.

    Here’s to a healthy and uneventful delivery and, far less importantly, to having the means to be financially secure regardless of what happens!

     

    #179283 Reply
    Avatar G 
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    I’m def still following!

    Although I dont think it would change your decision, I question the “state law” comment by the hospital billing person. Maybe “hospital law” that they bill insurance as opposed to trying to deal with an individual.

    Show me the statute that it is illegal to pay cash and I’ll stop steaming.

    https://www.consumerreports.org/healthcare-costs/how-paying-your-doctor-in-cash-could-save-you-money/

    #179297 Reply
    Liked by portlandia
    Avatar jacoavlu 
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    Quick update for anyone still interested/following: I called the hospital billing department today – apparently it is not an option for me to develop some kind of an all cash agreement rather than using insurance.  According to the person I spoke with it is a state law that bills must go to insurance companies if a patient has insurance.

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    my rudimentary understanding is that a facility can offer a cash discount if you are uninsured or “underinsured” and not run afoul of medicare rules, but I’m no expert.

    you should check mdsave.com as some places are beginning to offer services, including uncomplicated deliveries, with a prepaid discount cash price that is applicable even if one has insurance, and can even be counted toward a deductible in the case of an HSA plan. Locations and providers are limited at this point. There may be other websites with similar offerings that I’m not aware of.

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #179305 Reply
    Avatar Western wolf 
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    you should check mdsave.com as some places are beginning to offer services, including uncomplicated deliveries, with a prepaid discount cash price that is applicable even if one has insurance, and can even be counted toward a deductible in the case of an HSA plan. Locations and providers are limited at this point. There may be other websites with similar offerings that I’m not aware of.

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    Just checked – very cool idea but unfortunately services are not offered in my state.  The nearest state does offer the services but the price for a “Vaginal Delivery with Prenatal and Post Delivery Visits” is $10,500.  The fine print also clarifies that it would not include the pediatrician fee.

    This definitely seems like a great option for some of the other tests I was looking at though.  Would have saved me 500 dollars on our recent ultrasound!

    G wrote:

    I’m def still following!

    Although I dont think it would change your decision, I question the “state law” comment by the hospital billing person. Maybe “hospital law” that they bill insurance as opposed to trying to deal with an individual.

    Show me the statute that it is illegal to pay cash and I’ll stop steaming.

    https://www.consumerreports.org/healthcare-costs/how-paying-your-doctor-in-cash-could-save-you-money/

    Click to expand…

    I also was surprised by that.  I’ll let you know if I can find some proof that they were wrong (or right for that matter).

    #179325 Reply

Reply To: Considering signing out AMA after wife delivers – am I crazy??

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