Yves here. One has to wonder what might explain the increase in the appalling practice of patient dumping. The Health Care Renewal website has for some time been writing about the destructive impact of managerialism, as in rule by MBA, on the policies of large medical organizations such as hospital networks. But that even if ultimately true, is still an awfully broad brush.
I thought private equity might have something to do with it, since there was a spell when private equity firms were snapping up hospital chains until they found out the regulatory restrictions were sufficiently tight that they couldn’t do much to wring more in profits from them. I knew private equity experts Eileen Appelbaum (now co-head of CEPR) and Rosemary Batt had researched private equity hospital deals, and so I pinged Eileen. From her reply:
I haven’t investigated this, but have seen reports of patient dumping. I don’t think PE-owned hospitals are worse in terms of treatment of patients than other hospitals. We interviewed nurses who had worked in both nonprofit and PE-owned hospitals. They had some unfortunate stories to tell, but in both contexts.
Here’s something I wonder about. I happen to know a trauma doc. The hospital he works at – a major suburban hospital with a first rate reputation – has outsourced its emergency room to a trauma doctor practice. Before, if an uninsured, indigent person showed up at the ER, was treated, but couldn’t pay, it was the hospital that took the loss. The doctors got paid for their work in any case.
Now that the ER has been outsourced to the docs, they take the loss and don’t get paid for their work when they treat a patient that can’t pay. As they are not hospital employees, they also can’t do social admissions in such cases. As far as I know, his practice treats indigent patients – he grouses enough about having to work without getting paid. I’m sure he and his colleagues would not engage in patient dumping. But the financial incentives might lead others to do that.
Contrast that with Montefiore, where all the docs are employees on salary and the hospital actually rents rooms in the community in order to be able to care properly for patients who are poor and homeless.
By Dorothy J. McNoble, JD, MD, who can be reached at Badmedicine005@gmail.com
On a cold December night in Santa Cruz, California, a hospital employee at Dominican Hospital wheeled a patient out of the emergency room and left the patient on a bus bench in front of the hospital. The patient, a homeless man clothed only in a hospital gown was rescued by a passerby who realized that the patient had no clothing, no shoes, and no possessions and was unable to seek shelter or clothing.
A nearly identical incident occurred in Baltimore around the same time. This patient was “discharged” from the University of Maryland medical Center Emergency Room clothed only in a hospital gown and was unable to seek help or shelter. That patient too was rescued by a good Samaritan passerby who documented these events on his cell phone.
Both incidents were eventually reported by the media, and the Baltimore rescuer was interviewed by the host of “The Takeaway” on NPR. NPR also interviewed, Arthur Caplan, a well-known medical ethicist. He stated that these “hospital dumping” events have been occurring with increasing frequency in recent years, in spite of a specific federal prohibition against this behavior. He was referring to the Emergency Medical and Active Labor Act of 1986 which requires hospitals to provide emergency care irrespective of the patient’s ability to pay for that care.
Over the years, the law has been interpreted to specifically prohibit discharging patients from the emergency room or the hospital if they do not have the means to obtain shelter, and personal and medical necessities such as food, medicine and follow up care. I was surprised to read about these incidents and to learn that they are not isolated events. I worked for 30 years providing surgical care in hospitals which served large numbers of indigent, homeless, mentally impaired, addicted and otherwise socio-economically disadvantaged patients.
In my experience, hospitals routinely made “social admissions.” That is, patients who were without access to shelter and other basic needs were admitted to the hospital or kept in the emergency room until a “safe” discharge plan could be put in place. A phalanx of case managers and social workers worked to find housing, make arrangements for follow up in county hospitals or, in some cases, prepare expedited Medicaid eligibility documents so that some of the patients could even be placed in care or nursing homes.
Of course, many patients left, did not make it to their follow up appointments and otherwise ended up in a revolving door of social admissions, discharges and readmissions. However, in my 30 years, I never saw an instance of patient abandonment such as described in the two incidents above.
Would the hospitals where I worked have expended so many resources providing custodial care for the socio-economically disadvantaged patients if there were no federal “Sword of Damocles” (the EMTALA) law putting them at risk for prosecution? I do not know the answer to that question, but I can say that my colleagues never exhibited the cruelty or indifference described above, in spite of the often exhausting and overwhelming task of caring for these complicated patients.
I do not know if the changing economic landscape for hospitals is responsible for more aggressive “dumping” policies. Across the country, hospitals, in order to survive have merged into more profitable “health care systems.” which have a cancer-like expansion of marketing and administrative bureaucracies whose mission is to block access to indigent and Medicaid patients and attract the well-insured ones (In the past five years, hospitals have experienced a 3000% increase in the number of administrative personnel in these hospitals systems). The “financialization” of health care has meant that the health care dollars are increasingly diverted from patient care to profits and marketing. This is as true in the not-for-profit as in the for profit hospitals. One need only see the explosion of hospital advertising to realize that there is a serious diversion of money away from patient care.
Finally, in this era of reduced emphasis on regulatory compliance, there is the possibility that there may be decreased EMTALA enforcement. As I said above, I would like to think that hospital staffs would never abandon patients in need. However, the very need to pass an EMTALA law proves that such legal constraint is necessary.
In my recent experiences with my mother and the hospital system, stay times are dictated by the insurance … including Medicare. Some patients definitely need to stay in longer than is allowed by the financial straightjacket. And this isn’t new, this was true 28 years ago, when my wife gave birth to my daughter … though it worked out fine for both of them.
The problem is financialization, which has inevitably extended itself to medical care.
Both sides of the medical insurance border are affected by the financialization of healthcare. While those without insurance are discarded; those with insurance are harvested (the wheat from the chaff).
On the harvesting side, parasitic protocols have evolved to extract as much wealth from the host (the hybrid of the insurance plan and the
patientco-payer) without killing it (the two payment sources). The patient is offered the “just to be safe” rationale to encourage them to agree the whatever the most profitable treatment and diagnostic protocol of the day is, while the insurance companies are encouraged to buy into the same under the rationale of malpractice avoidance and long term “Lifecycle” cost savings.
Sitting on top of this dynamic is the fact that the insurance business is a cost plus business model. The greater the costs, the greater the vig of profit. The healthcare market, as it tends to a fundamental human need, is much more prone to monopolistic price evolution. If car insurance (as part of the cost of car ownership) ultimately rises too high, its market tends to adapt towards other means of transportation until a balance is achieved, but when healthcare (insurance plus copay) becomes unaffordable (being a fundamental need) the market response is usually genuine panic or revolt.
The healthcare system, and the people who participate in it, are not evil. They are merely human beings following their respective flock behaviors through a fatally flawed macro model; each chasing their corresponding in systematic incentives. If we hope to find a healthy model, we must build a sustainable macro model. Only a holistic approach will work because the interplay between many of the components create an unsustainable feedback loop. We must also understand that markets around basic human needs (food, shelter, and personal safety) interact with market forces in their own unique ways, and therefore cannot be fixed by approaches that are successful in other markets.
Well that happens when people/politicians think healthcare happens from magic. The skyrocketing costs of course have nothing to do with actual care, but for things and people that provide ZERO care to patients. Having just received a bill (which will be paid by Medicare) for an elderly parent, the cost for a 3-day stay was over $14K, actual physician treatment and testing was less than a third of the bill.
Of course I reign from the state where the architect of the current healthcare law (which OPM decided to say Congress, staff and families are exempt from), who intentional designed the system to fail. Since MA was already a ridiculously high medical costs state to begin with, the hit wasn’t as bad, however the outcomes of healthcare in a First World country still suck. It doesn’t help that Americans in general are walking healthcare disasters because they can’t help putting such shit in their bodies to begin with.
That sounds like a pretty good deal. In Nov my cat had surgery for a broken hip (that she didn’t ultimately survive) which cost over $14k
Good to have that kind of disposable income to spend on an animal I guess.
The old top down approach in America. Those at the top have to really get theirs, so those in the middle and bottom better punch down if they want theirs.
But this attitude infiltrated medicine years ago as doctors started to turn an envious eye to dotcom kids and trader bros that make multiples of their salary doing jobs that the doctors rightly think as less important as their own. I recall seeing an extended article in the Harvard Med School alumni magainze saying it was a doctors right to maximize profit over doing good and ethical works. Yeesh. So witness patient dumping and surgeons at MGH double billing surgery and all the other tricks that go on to line the medical care professionals pockets at the expense of the patient.
The “situation” may be even more dire than this article and the introduction suggest, both for dumping and for delays and denial of care to the poor. My dog and I take the “last walk of the night” something after midnight. I live by Columbia University on the cusp of Harlem and work part-time in the valley below. In both areas, the “gentrification” is brutal. Those still clinging to life in their old neighborhoods are not well-served by the hospital conglomerate that bought out the university’s teaching hospital and nearby medical services organizations. On four occasions, I have come across elderly, dumped patients who were too weak to walk the ten blocks or so to their homes. I braced them and got them home — and I am well past retirement. It wasn’t so difficult that a cab or an orderly could not have done the same. More significant is the intentional delaying-in-order-to-deny care which I have now witnessed with a Medicaid patient whose operation — repeatedly recommended by ER staff only to be overturned by “administrators” — would cost about $5,000, most of it covered, as I understand it, by the government. My sister is a doctor. I have ghost-written medical books and been a clinical medicine reporter. . . still have friends in the business, and I cannot believe what I have lived and witnessed. Whether we use fancy terms like “financialization” or something plainer, I think even Dickens would shudder at what America has become. I sure do.
This thread and, in particular your contribution, inspire sadness. A lot of it. Yes, I agree that “financialization” does sound too fancy and polite to define the situation that you and others are describing. Dehumanization could be the proper word.
You post brought me to tears. Why can’t we face up this this problem in the US? The elderly are especially victimized. So very, very cruel and disrespectful.
Larry – I’d be very interested to see the article in the Harvard Med School alumni mag that you reference. Any chance you could provide a reference?
For years I worked at a major hotel located a half-mile from a county-run mental health facility. Across from the hotel was a city park. It was common to see ex-patients wandering onto the hotel “campus,” very disoriented. The hotel security guards would then escort these poor fellows to the city park, where they would live for days and days, until the police arrived to deal with them. The police would cart them to some sort of holding jail, then transport them back to the mental hospital for a 96-hour commitment. The only way to get out of the cycle for some of these unfortunates was to commit an actual crime, which would land them in the city jail farm for a spell. That was the full cycle: hospital, homelessness, police, judicial system, jail, homelessness, and then back to the mental hospital. It was a problem that most of our city and county officials refuted to acknowledge or rectify.
Applebaum said: “I don’t think PE-owned hospitals are worse in terms of treatment of patients than other hospitals. We interviewed nurses who had worked in both nonprofit and PE-owned hospitals.”
The idea that nonprofits are somehow less $$$-driven than for-profit facilities persists, but it is Wrong, Wrong, Wrong. My favorite example is the “non-profit” Cleveland Clinic. I defy anyone to find a more dollar-driven enterprise on the face of the earth. Cleveland’s other “non-profit” hospital corp, University Hospitals Inc., tries to rival the Clinic in this respect, but I don’t think it quite manages to keep up.
The Cleveland Clinic’s status as a “not for profit” is an artefact of the US tax code, not its business model. In colloquial English, it is alarmingly profit-driven. It reluctantly shares a near regional monopoly with its competitor, the University Hospital system.
The Clinic may not generate “profits”, but its surplus is considerable. The luxury of its executive elevators is said to be Trumpian. At one time, it’s ER room could be identified by a small unlit plaque, virtually unreadable at night. It has apparently become more typical. And like NYU, it is reportedly the largest landowner in its slowly gentrifying part of Cleveland.
Uganda knocks out the middle men!
Years ago when I worked at a community mental health center I heard of incidents where a psychotic homeless patient would be sedated enough to be able to take a funded bus trip back to their home town where 1. they supposedly had a “support” system and 2. that locality would have to fund their eventual hospitalization. Where I worked the option would be joked about to cover frustration and despair over trying to help someone who seemed beyond hope, not as something we’d ever do ourselves, of course.
There were articles about this. Hospitals in California were reportedly buying busfare for their evictees and sending them to Las Vegas and elsewhere, according to what I remember. They were sued (by the destination towns?) and hopefully stopped doing it. The articles came out a couple of years ago.
This is the same practice described in the old nursery rhyme “Three Men in a Tub.” Medieval towns would take their insane, lepers, and other “undesirables,” put them in a boat (“tub”) and push them off into the river to float down to the next town and become their problem.
Rinse. Repeat. Until…they came to the sea???
There truly is nothing new under the sun when it comes to the greed and depravity of the human species….
Lately I’ve noticed the term of art is increasingly “client” rather than “patient”. I’m not sure why that is, but I guess firing your client by throwing him or her out on the street sounds less immoral than for a patient.
“Patient” is no longer politically correct in much of the medical field, especially mental health, the sector in which I work. On hospital wards that treat physical problems, “patient” is still permissible, although that is changing slowly. “Patient” is considered demeaning in psych (by the high muckety-mucks who issue linguistic fatwas), because implies that the person receiving care is in a subservient position whereas they’re equal participants in their treatment decisions, blah-blah-blah. “Client” or even worse “consumer,” is the preferred word. Different managers and workplaces have different degrees of doltishness about this. My last boss on a big-city hospital psych unit in Vancouver, B.C. jumped down the throat of anyone who used the word, even in the middle of staff meetings. In the Australia it’s frowned upon but not outright forbidden. There’s a double standard between how nurses and doctors TALK and what they write in progress notes. We say “patient” but censor ourselves when we’re composing notes to use the PC words.
The article by Bob Hertz a couple months ago had some good comments on the regulations that encourage patient dumping: https://www.nakedcapitalism.com/2017/11/medical-cost-reduction-act-2017.html
Safety-net hospitals should receive federal aid for emergency care. The emergency room is in part a public service, i.e. part of our infrastructure – and taxpayer funding must play a role.
For example, EMTALA regulations require hospitals to stabilize any patient, regardless of payment – but EMTALA has never had any funding! Hospitals are even required to try and collect from patients, before getting federal help for bad debts. This is all dishonest: If we demand that hospitals provide a public service at less than full charges, then we must compensate the hospitals.
Demanding the hospitals cover patient treatment without reimbursement is practically begging for the problem at hand.
There’s no hope that we can move to a more cost-effective system so long as the EMTALA is in play. It’s functionally a slam dunk for those who care about Good Intentions, but there’s no free lunch and those of us who make the tough decision to forego medical care seem to pick up the bag for those who make the easy decision to show up at an ER and ask for whatever.
Why don’t we ever hear medical ethicists talk about the chattel class who’s coerced into paying for this bologna?
If you have nothing for the hospital to go after, no assets, nothing to lose, I guess it’s an “easy decision”. For everyone else who gets care under EMTALA there’s nothing to stop the hospital for going after whatever you have.
I am more persuaded of the ills of managerialism – rule by MBA – in areas where their priorities detract from rather than enhance the provision of services. That happens through elevating profitability over all other goals, not in competition with but in place of other priorities. How else to explain an elaborate coding and protocol to deliver an $8 aspirin to an in-hospital patient?
All business, it seems, outsource parts of themselves in pursuit of the highly profitable “virtual company”. Marketing devices attempt to hide the cuts from customers, who rarely see prices drop. Perhaps fair in the manufacture and sale of widgets. But that assumes no competing priorities, such as avoiding monopoly or environmental predation, or public safety. In providing medical services, there would seem to be many competing priorities.
Take Eileen Appelbaum’s anecdote about the outsourced hospital ER. Managers atomized the normal structure and separated the hospital from its trauma center. It sidesteps the hospital’s responsibility to admit emergency patients. As non-employees, trauma physicians could only recommend admission, not demand it. It provides a filter to reduce the unfunded obligation to treat non-paying patients. It lowers the hospital’s liability for the standard of care those trauma physicians provide. And it provides a revenue stream through lease and other payments for hospital facilities the trauma physicians use.
But what’s the motivation for this corporate restructuring? Not to improve patient care. None of these steps address that. Adding bureaucratic hurdles to admission of ER patients cuts the quality of care, as does pushing more administrative work and economic risk onto physicians.
The Truth Behind That Baltimore Patient Dumping Video
Dr. Damania blogs as ZDoggMD. He posted a video that covers the Baltimore episode in some detail, the essence of which he posted on this essay in Medium. He was in contact with some hospital staff who were able to convey additional information regarding this patient and the circumstances surrounding the greater issue.
“We look to our hospitals, to our doctors, to our nurses, to our respiratory therapists, to our social workers, to our psychiatrists, to our case managers, to our discharge planners, to solve the problems that we’ve been collectively too craven to solve ourselves. Then when a tragedy like this is documented on video (and this is just the tip of the iceberg), we ignore our failure to manage the root cause of the problem, instead pointing at the nearest scapegoat. People are outraged at the emergency department. Yeah, you should be outraged. You should be mad at the emergency department for failing in the face of impossible odds. But you should be furious at the larger system that failed this woman and hundreds of thousands of others like her who suffer daily.”
Or the video and longer essay:
Patient dumping has been going on in Los Angeles for years. I first learned of it back around 2001 and by then, it was already an established practice.
Area hospitals drop patients off on Skid Row so that missions would take over.
There were also buses that would bring shelter residents from area communities in the morning. They could stay over night in the shelters but during the day they had to disappear.
Interesting question. These people who were dumped in their (backless, you know) hospital gowns. What happened to the clothing they were wearing when they came in? Were they stark naked at that point in time? That seems surprising. Their clothing appears to have been stolen.
Mr. Burns: Attention, workers! While you were all in the showers I sold your clothes.
Carl: Not again!
See my comment below. The fact is, we may not be getting the whole story.
That’s occurred to me too. Even some worn clothes costs money and even a homeless person would probably have a wallet with maybe their ID…
Hmmm, I just realized that dumping someone without any clothes or papers would make it harder for anyone to follow the dumped one’s trail from the dumper. Or maybe they couldn’t be bothered. Sending them out dressed with their own clothes would take some extra work.
The State of Nevada government was shipping its mentally ill patients to cities in California using Greyhound Bus.
To expand upon what Elizabeth Burton said below re: “what happened to the clothing they were wearing when they came in?” you should consider what sort of stuff desperately ill people have on. It’s often stained by their own urine, faeces, blood or vomit. Sick people don’t have control of their bodily functions. It might be ripped or filthy. Sometimes the combative ones who are brought in by police have clothing reeking of capsicum spray (Aussie term. “Bear spray” in Canada, “pepper spray” in the U.S.) The clothes might be full of bedbugs, so we have to bin them. Those are some of the reasons we dress patients in hospital gowns. Hospitals are horrible about losing patients’ possessions, including clothes. After we put someone in a gown and whack their togs in a plastic bag, the patients get shuffled from one cubicle to X-ray, then to another cube, after that to the short-stay unit and so on. Whoops! — we forgot to transfer the clothing bag at one link in the chain of movement, we were so busy. Not good, but it happens. For the sort of old, confused, mentally ill, friendless, desperately poor (and combinations of those categories) who get dumped by hospitals, there’s no backup people to provide second sets of clothes. For many of you who have enough free time and mad computer skillz to be typing comments on econoblogs like NC, you might not grok how close to the bone lots of folks are living, where they literally don’t possess much more than what they’re wearing on their backs.
As one who has live fairly close to the bone, I can understand that, and I can certainly understand why sometimes stuff either gets lost, or are in so awful a condition that they have to be destroyed. That is life; poor people do have the habit of having their possessions lost, or destroyed, frequently by others. Of course, when one is living so close to the edge, whatever you have is even more important.
I have read a number of stories over the years about police taking and destroying peoples possessions including records, medications, clothes and whatever else a person has with them as they are being moved alonged, evicted, or arrested. I am sure the police will mention how nasty their stuff was and how busy they are. Now I can add stories about hospitals too. It seems to be a thing to not give a damn about it. What’s a little more humiliation, or impoverishment, as it’s only “those people” right? Well, I give a damn. And I am using my “mad computer skillz” to say so.
Anyone of us might become sick, mentally ill, unemployed, or just old, and I would hope that those who are supposed to help those most in need would remember that, rather than make excuses, or blame the victims, for the mistreatment.
Yves- re your trauma doc acquaintance –
It would be highly unusual for a doc group to take on the financial risk of ER care. Usually the group demands (and gets) a subsidy from the hospital.
If the doc is complaining about inadequate pay, he’s ultimately complaining about his pay from the company he works for, most of those companies are owned and flipped to each other by venture capitalists.
Appelbaum knows this individual pretty well and it’s not VC owned. The docs own it.
My wife and I have no insurance; we are in our early 60s. We make too much to get offsets from the ACA, so we self pay every time. The “best” deal we could get from ACA was $12,000/yr premiums and $12,000/yr deductible. That’s the cheap plan.
She has been to the ER twice in the last two years, and each time required a two-day stay. Total cost: $6000. That includes everything. By working with a Catholic hospital and getting the self-pay menu, we saved 67% right off the top. The FO gave us 18 months interest-free to pay each time. Additional costs were from regularly scheduled doctor visits, blood work, etc. We save a ton on prescriptions by always going with the generic when possibile, and getting others from a big discount club. Most scrips run about $4/mo. This is less than we would co-pay with insurance. We didn’t even pay enough to itemize. It was lower than our standard deduction each tax year.
A lot of people our age are “surviving until 65”, waiting for Medicare to kick in. Many others are getting robbed blind by premiums. There is a better way, self pay. Hospitals and care givers will work with you on payments and you will save far more.
I’m not sure which was being referenced, but following the reporting of these incidents, I happened to read a response from a hospital worker. For obvious reasons, they couldn’t address the specific incident or say what position they occupied, but they did offer an alternative that never made it into the “look how badly these poor people were treated ” stories.
What if, this individual posited, the patient in question was not only mentally ill but belligerent to the point of violence, refused to accept treatment or medication, and then refused to leave when told by staff they couldn’t do anything more for them. What if that refusal included putting their clothes on? What if that individual was making it impossible for the staff to treat other patients? And what if the patient in question were a known repeater?
The suggestion in their post was that they were personally familiar with one of the incidents, but having worked a few years with a health care provider I can attest that kind of situation isn’t all that unusual—and I was in a rural area. I can only imagine the problem is multiplied by many factors in major urban areas.
The difference between back then and now was that we didn’t have people with smartphones who could, without knowing anything about the situation, post video that gets picked up by major media who are always happy to “expose” a scandal. Factor in that today’s media are only passingly familiar with the concept of getting both sides of the situation and an institution legally prohibited from discussing same; and it’s all too easy to expand a tiny number of isolated incidents into a nonexistent scandal.
I’m not saying patient dumping doesn’t happen, because I know it does. And perhaps it will be a good thing if these two incidents focus attention on it. However, I find it hard to believe the issue will be exposed in an age when corporate interests determine what we see, hear, and read in the media and investigative reporting of the caliber of the late Robert Parry’s is a historical footnote.
These stories were both reported in the press, and thus not mere anecdotes. That also means the reporters contacted the hospitals and they didn’t try to defend what they did. There have been stories like this out of LA hospitals for years, as readers above indicate.
Urban psychiatrist perspective. What medical condition did these homeless individuals have? Perhaps they have no more Medicare inpatient days for mental illness and are known ‘frequent flyers’. What makes a hospital the shelter of last resort? Surely society as a whole is failing, but perhaps acute care beds aren’t the most efficient place, even with payer sources.
These type of frequent flyers brought in by police or EMTs usually put on a stretcher in back of ED & sleep it off, till next time.They would get ID band & some changed into gown with belongings bagged & left on or near stretcher. Sometimes these “patients,” those with dementia, or with delirium from medications have wandered. Later found outside by security and brought back. Most hospitals work with community to find housing to keep them out of busy ED. Have read about the LA dumping & Vegas buying the homeless & psyche patients one way bus tickets to California.
This was what I referred to above. Dr. Damania was in contact with several people who are familiar with the situation. His video is worth watching if you wish to have a better understanding of the circumstances surrounding the Baltimore case. And as a retired ER doc with nearly 20 years of experience, I can relate. The ER has become society’s dumping ground, and society has left the staff with no options.
I had a ward of the state on a locked unit for over six months. He was well the last two after starting clozapine. The guardian was threatening our social workers with license investigations ‘ if he’s sent to a shelter and something bad happens’. I called BS and informed them he no longer needed hospitalization and would be sent to a shelter and, lo and behold, the state found a placement. But two free months of room and board in the meantime…
A simple google search on patient dumping Los Angeles will turn up articles going back years. This is not new. I learned of it first hand when I moved to Downtown Los Angeles in the late 1990s. I kept seeing patients in hospital gowns on the streets. Finally asked what was going on and that’s how I first learned about patient dumping.
Again, this is not new.
More likely to be exceptionalism and special pleading rather than representative of the problem.
Patient dumping has been a thing for more thirty years and it is getting worse.