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.