Career resources content posted on NEJM CareerCenter is produced by freelance health care writers as an advertising service of NEJM Group, a division of the Massachusetts Medical Society and should not be construed as coming from, or representing the views of, the New England Journal of Medicine, NEJM Group, or the Massachusetts Medical Society
Physicians are on the move. The dynamic nature of the current practice environment is the catalyst for a significant number of physicians relocating at some time during their careers, especially in the first few years. Once a decision to move is made, clinical and administrative notifications must take place in a timely manner. In some circumstances, such as relocation to another state, new agencies must be contacted and licensing and professional liability requirements must also be met. Early planning and notification are the keys to a smooth and successful transition.
— John A. Fromson, MD*
Myriad issues, from legal and practical considerations to personal details, need to be addressed when leaving a practice.
By Bonnie Darves, a Seattle-based freelance health care writer
The Marcus Welby, M.D., approach to a medical career — setting up practice in Hometown, USA, and staying put for four decades — still happens, but these days it’s increasingly rare. With an estimated 40 percent of newly practicing physicians choosing to leave their initial practice opportunity within two years of joining the group, and a much smaller number deciding that the solo act is not for them, there is a lot of “movin’ on” that transpires in any given year.
For physicians who decide to relocate or join another practice, planning carefully for the move and anticipating the myriad issues that might come up down the road are essential. Depending on the circumstances that prompted the decision to leave, the tasks associated with orchestrating the move can range from a weekend’s worth of work to weeks and months of planning for and attending to the details.
Even when the move is merely a straightforward relocation — leaving a group in one state or city to join another elsewhere — it’s essential to begin planning several months ahead, if possible, suggests Joan Roediger, JD, a health lawyer and partner in the Philadelphia firm Obermayer Rebmann Maxwell & Hippel, LLP. “Step number one is ensuring you have taken the time to find the right opportunity, but even before you start the job search, it’s a good idea to take a look at your current employment contract,” says Roediger, who specializes in physician employment agreements and related contractual issues and frequently lectures on those topics.
Often, Roediger says, young physicians are so anxious to start their first practice position that they pay scant attention to what might be involved in leaving it. Many employment contracts, even those that contain “without-cause” clauses allowing physicians to leave at will, stipulate that ample notice be provided — in some cases as much as 60 to 120 days. “It’s a very important consideration,” she says. In addition, physicians who plan to practice in the geographic area should review patient-associated contractual obligations or prohibitions, such as non-compete or non-solicitation clauses, that could affect where or how they practice.
“Most employment contracts will state that the patients are the practice’s patients, not the individual physician’s. So if the physician is moving across town rather than across the state, there typically are covenants that prohibit the physician from taking those patients,” says Bruce Johnson, a Denver health lawyer and consultant with the Medical Group Management Association.
Of equal importance is planning for timely notification of all of the individuals and entities affected by the departure, from colleagues and patients to health plans and malpractice carriers. Colleagues and malpractice carriers should be informed of the prospective departure date as soon as feasible. “Six months before leaving is too soon to notify your patients, but it’s not too soon to tell your colleagues or to start looking at your managed care contracts to determine your notification obligations to health plans,” advises Margo Williams, a practice management associate with the American College of Physicians in Washington, D.C. For example, some health plan contracts are structured with the group, others with the individual physician. Practically speaking, the former arrangement could mean that the departing physician must essentially reapply to participate in the insurer’s network in the same region or in another state.
When notifying health plans, sooner is better, Johnson urges, and at least 60 to 90 days’ notice is recommended. That time period enables insurers to reconfigure their network, if needed, and allows ample time for them to remove the physician’s name from the preferred provider list. In addition, timely notification may prevent problems down the road, such as improper retroactive payment adjustments, Johnson explains.
State and specialty medical societies, medical licensing entities and the Drug Enforcement Agency — as well as state prescriber-monitoring agencies, if applicable — should also be notified as far ahead as possible, advises John Fromson, M.D., chair of the Department of Psychiatry at MetroWest Medical Center in Massachusetts and a member of the Harvard Medical School faculty. “It’s important to ensure proper notification of any regulatory agencies to which you are tethered,” Dr. Fromson says, adding that physicians should follow those entities’ policies to the letter to ensure there is no possibility of the departure being misconstrued as patient abandonment. For example, the Massachusetts Board of Registration in Medicine requires physicians to notify the board of any change in status.
Review of contractual obligations is essential
On a potentially more problematic note, physicians planning a move should carefully review all contractual arrangements that will affect their personal finances and professional liabilities — in the months following the move or years into the future. For example, while most employment contracts spell out how accounts receivable will be addressed should a physician leave the practice, sometimes clarification is needed or warranted. “Just as you have to go through certain procedures when you join a practice, to ensure you’ll get paid, the same goes with leaving a practice,” Johnson says. For example, if the employment contract doesn’t address how and when accounts receivable owed to the physician will be sent, an “exit agreement” should be drafted to address those details. That agreement should also grant the departing physician access to the practice’s financial records, in the event of a payment dispute.
On the other side of the picture, physicians should be well aware of contractual obligations or debts that might follow them to their next position. Those who have become partners or owners in the practice they are leaving might have signed on to building or equipment loans, for example, or may have limitations on their partnership buyouts, Johnson notes. “Medical groups often have purchased buildings or equipment through a separate partnership. And though you might be able to cease your employment with the group, the partners — or the bank — might not be willing to let you out of the personal loan guarantee,” he says, despite attempts to negotiate a termination of those arrangements.
Once colleagues have been informed and contractual issues addressed, physicians who are leaving the local area should provide ample notification to all of the institutions where they admit or treat patients: hospitals, nursing homes, clinics and rehabilitation centers. Roediger advises starting with a telephone call to those facilities and then backing up that call with a letter that restates the date of departure, the names of physicians to whom patients should be referred (if appropriate), and how the departing physician can be reached. “I think it’s a good idea to first call any place where you go to treat patients, to reach out personally, especially when you have had a good relationship with the staff,” Roediger says, adding that physicians should be sure to mention that they have enjoyed the opportunity of working with the staff and administrators. “After all, you never know where your future career may take you, so it’s important to leave on good, friendly terms.”
The confirming letter, which should be sent a few weeks in advance of the physician’s departure, should include the names of patients still under his or her care and the name and phone number of the physician(s) who will assume responsibility for those patients. “That’s good not only from a legal perspective but also from a relationship-building perspective,” Roediger says.
Parting with patients: timely notification, smooth transition key
Physicians who are leaving the state should ask licensing boards and medical societies about any related requirements regarding patient notification or recordkeeping. State statutes regarding what constitutes proper notification or, on the other end of the spectrum, patient abandonment, vary considerably in their specificity and their requirements. As such, it’s important to obtain a grasp of those requirements before embarking on exit planning.
“There are few statutes out there that say you must give X days’ notice, but some do. Most tend to be based more on what is considered a reasonable approach,” says Roediger. “In a perfect world, I recommend that physicians give at least 30 days’ notice, unless it’s an emergency situation or the departure is unplanned.” Some states also require that physicians leaving the state post a notice in the local newspaper announcing their planned departure.
In addition, certain specialties have established policies governing what constitutes ample notice to patients deemed active (those who have been seen or treated within the previous two years). Internal medicine physicians are urged to provide at least three months’ notice, and psychiatrists six months’ notice. The American College of Gynecology and Obstetrics’ policy requires that physicians refrain from closing their practices until all patients who have reached their 20th week have delivered.
“This is an important issue, so physicians should check with their specialty society about notification policies and procedures,” Dr. Fromson advises. He also recommends that physicians take extra steps to ensure that the physicians who have agreed to take over care of the patients are prepared to do so and are planning ahead. A verbal initial conversation should be followed up with a written “reminder” letter, Dr. Fromson suggests.
Physicians also should be aware of all federal and state laws governing retention of and access to patient records, as the latter can vary substantially from one state to the next. It’s also crucial that departing physicians arrange, through a legally binding agreement, for future access to patient records and that they provide records release documents to patients, if applicable. That access might be needed in the event of a malpractice claim or a payor dispute, for example.
Assuming the physician is leaving the practice on good terms and with ample time to prepare for the departure, the key consideration is ensuring that patients are properly notified in a timely and professional manner. Even when the patients have the option of remaining with the practice and likely will choose to do that, they should be advised by letter of their options and where their records will he kept — and informed of the steps the physician will undertake to manage the transition. It’s good form to thank patients for the opportunity to care for them and to assure them they’re being left in good hands. It is also vitally important to seek input from the other physicians in crafting that letter, Johnson advises, to ensure its tone and message are appropriate. “I think that’s the right thing to do for both patient care as well as the benefit of the practice. In fact, physicians can find themselves in hot water if they write that letter without coordinating it with the practice,” Johnson says.
Writing an appropriate “good-bye letter” can be difficult for physicians who haven’t done it before, so it’s a good idea to tap available resources before tackling the task. For example, physicians who are employed by a hospital, an HMO, or a large group practice may discover that the organization has specific policies or procedures for patient notification, or templates or wording conventions it uses for such purposes. “Check with your employing organization first because perhaps you won’t have to start from scratch or ‘reinvent’ the document,” Dr. Fromson says. “Also, there is no reason to feel alone because you won’t be the first physician to have made a move.”
Moving On: A departure-planning checklist
Three to six months ahead:
- Review all contractual arrangements, especially the current employment contract and managed-care contracts.
- Notify colleagues, professional societies, specialty boards, state licensing boards, and malpractice carriers, and contracted health plans. (If moving to another state or jurisdiction, similar agencies must be contacted and licensing and professional liability requirements met as well.)
- Inquire about state-mandated responsibilities regarding patient transfer and recordkeeping.
- Check with the specialty society regarding its policies and recommended timeline for patient notification. In psychiatry, for example, six-month notice period is urged for all active patients.
One to three months ahead:
- Notify administrators and staff at all facilities where you admit or care for patients. Start with a phone call and follow up with a detailed letter that also includes future contact information.
- Notify patients in writing, through a letter carefully crafted with input from practice colleagues or the employing organization, if applicable. The letter should specify the date of departure, patients’ options regarding providers to manage their care, and how and where their medical records will be stored.
*Dr. Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.