Do Advocates Have a Duty to Report Dangerous Patients?

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Warning! This will be one of those posts you think back to from time to time, because the answers aren’t clear or easy, and the stakes are so high.


A few weeks ago we all watched the news about 150 people who lost their lives as their plane crashed into the French Alps; a tragic loss of life which we learned later was caused by the co-pilot, who had intentionally crashed the plane – suicide by one – mass murder of 149 others.  Horrible, tragic, and just so very, very sad.

It’s easy, of course, to dismiss the young pilot as crazy – depressed, suicidal, truly an example of mental health gone awry.  But if you’re like me, the next thought that pops into your head is a question, “Could it have been prevented?”

Once I learned of the pilot’s mental health issues, and the fact that his doctor had written a note to keep him from working, I wondered how exactly that had taken place. Writing a note isn’t the same as actively reporting to the authorities (whoever those authorities might be) unless a copy of the note was delivered to those authorities… (And as an aside, I wonder if the doctor stopped at handing the patient-pilot a note telling him not to fly, and didn’t report it to the right authorities, and if so, how does he sleep at night?)

But even more importantly, what are the rules or laws in the US? Is there any responsibility to report a patient who is dangerous to himself, or certainly others? Could a provider be held legally responsible if he did – or didn’t – report?  How does HIPAA affect the assignment of responsibility? If there is a duty to report such a patient, where is the line drawn? How does that reporting take place?  And how does one decide whether a patient is truly dangerous to someone else, or just him/herself – or even truly dangerous at all?


I’ve been there. I’ve reported.

When I was a first grade teacher, many (many!) moons ago, teachers were mandated to report suspicion of child abuse among our students. One of my students, David, repeatedly came to school with black and blue marks, or a sore arm…. I would ask him how he got hurt and he had a new story every time — including the day he came to school with a black eye. When I asked him how he had gotten a black eye, he responded, “My mother said I fell down the stairs.”

And then I knew I had no choice but to report David’s situation. I was so upset to be put in that position! I was in my mid-20s at the time; still wet behind the ears. My hesitancy was a fear that when I reported it, David’s life would become even more difficult for him. Would he be taken away from his mother, perhaps thrown into foster care? If so, would that be a good thing in the long run? Or?

But none of those questions were mine to ask or answer. The law was the law. And I reported David’s injuries to state authorities.*

…..(end of sidebar)

Healthcare Professionals and the Duty to Report

So out of curiosity, I went looking for answers to my questions about providers and dangerous patients, and I learned something I had never known before, even after ten years of helping patients become smarter about navigating their care.

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Sorry. That’s Not Good Enough

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scoldingwomanOne of the most visible changes in the new health insurance reality are the medical bill surprises people are receiving that they never received before, for services covered previously as a matter of course. You know – whereas their insurance automatically approved a CT scan for purpose X in the past, now patients need pre-approval. Without that pre-approval, payment for that CT scan comes out of their own pockets – totally unexpected and usually very expensive.

Most of us learn the hard way that we need to get permission for many of the services that used to be automatically approved. I know I did. About two years ago I received the full billing ($350) for my annual trip to the dermatologist. I had been referred by my primary, the check-up was a covered benefit, but because I hadn’t gotten it approved ahead of time, I received the bill, and was told I was responsible, for the full ride.

I was stunned! And angry, too…. When I called my insurer, the customer service rep told me that was their new policy, and I was out of luck; there was nothing she could do to help me. When I asked when the rule had changed, she told me she wasn’t really sure. When I asked why I had never been notified, she said she didn’t know… Bottom line, I got NO information from her. I finally asked to speak to a supervisor who was even less helpful – until I told her I would be in touch with the state insurance department. Only then did she say she might be able to help me sort out the billing. Eventually they did cover the cost of my appointment – because they couldn’t prove to me that I had ever been notified of the change in policy.

I’m not going to lament here the fact that it seems like nothing can be done by customer service these days without threatening them first. Instead let’s look at some lessons for advocates; that is, that when we know we need something, or when we are stonewalled, the only real answer is “that’s not good enough.”

I raise it today because it almost happened again last month, as follows:

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The Weakest Link

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weakestlinkRemember that TV show from a decade or more ago?  When a contestant failed to answer a quiz question correctly, the host would sternly declare, “YOU ARE the WEAKEST LINK. GOOD-BYE!”  Remaining, of course, were the more knowledgeable contestants, presumably a stronger chain of smarter people who could get the job done.

Oh man, how I wish I had been able to invoke that host’s dismissal powers this past week!  As both my husband and I had to deal with different parts of the healthcare system, we encountered roadblocks – the weakest links – and in each case, we had to go over their heads to get what we needed.  THEY were the weakest links.  The problem is, they are still working there, stymie-ing patients every day.

And over and over again, the words of so many of you echoed in my head, Continue Reading →


You’re Not Charging Enough, and It’s Hurting Our Entire Profession

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  • What is it worth to find someone who can save your life?
  • What is it worth to find someone who can provide quality to a life that has little or no quality because of health problems?
  • What is it worth to find someone who can save you tens of thousands of dollars, or to prevent you from going bankrupt?
  • What is it worth to find someone who can alleviate your fear, and provide peace of mind?


I can tell you what it’s worth based on what I read in the press, in the APHA Forum, in my email and based on feedback from many of you:

On the high end, it’s worth about $350 an hour.

But on the low end, every day, many of you behave as if it’s worth is $0. Nothing. Zero. Nada. Zip. 

And in most cases, you don’t realize that is what you are doing.

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Saving Your Clients from Jerks, Crooks and Malintents

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(Apologies for the lists that no longer work in this post. In early summer 2014, deleted almost 1000 posts and articles I had written. The points below are still valid, but I wanted you to know why the links may not produce what you expect.)

I’m angry. And I’m appalled, too. And I think that you, as advocates, can be effective gatekeepers, guarding your client-patients from these kinds of providers.

fingerI’ve just finished blogging at about two situations that have come to light recently. A third belongs here, too – from the general news.

  • The story of an orthopedic surgeon who practices right in my own backyard, replacing and resurfacing hips. He has been accused (and has lost his job, and his hospital has been sanctioned) of waiting until his patients were anesthetized, then whacking them on the buttocks and calling them derogatory names. Yes, seriously. He has now left the hospital where all that took place, but has simply taken up residence in a hospital a few blocks away – meaning – he and his obnoxiousness are still performing surgeries everyday. What a jerk!  (And – I have to wonder – how is it that he did hundreds of these surgeries and none of the other OR staff reported him? How did they sleep at night?)
  • The story of a now-patient advocate whose wife died of bone cancer several years ago.  She underwent spinal surgery and it went badly – very badly. The husband (who is now a member of APHA) tried to reach out to the surgeon after the surgery, but the surgeon refused to speak to him. So, on the suggestion of his counselor, the husband began to blog about his experience. Immediately, through her attorney, the surgeon asked him to remove the blog posts from the web, and he did. But a few years later, the surgeon sued him for defamation! I’m sorry, but any surgeon who would refuse to speak to the spouse of a patient who had suffered at her hands, and who would, years later, sue the husband for trying to get past his grief – THAT is a malintent.
  • The crooks are those doctors who are committing fraud in several ways, from conducting unneeded tests and procedures just so they can make more money, to stealing from the government (our taxes) and from your clients’ pockets.  They are the doctors who are committing Medicare fraud, or they are balance billing or upcoding, all of which are illegal. These doctors are crooks, plain and simple, stealing patients’ health and money, and because they do it on a grand scale (stealing from payers), they are stealing from us all.

So what does this have to do with patient advocates?

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