Hospital ‘Dumping’ of Poor: Lawmakers Seek a Cure

In Alameda County, Sharon Ford, a Medi-Cal recipient, was turned away from two private hospitals last December while in labor, because a hospital computer erroneously showed that she did not have insurance. Hours later, her baby was born dead at Highland General Hospital in Oakland, the county facility.

The Alameda County district attorney decided against filing criminal charges in the case, but concluded “it is unmistakably clear that this transfer should not have been attempted.”

Economic Reasons

In San Bernardino last winter, a patient with a stab wound to the heart was sent to the San Bernardino County Medical Center after being examined and declared “stable” by a cardiac surgeon at another hospital, according to Dr. Max Lebo, the clinical director of emergency services at the county hospital. The patient arrived moribund, had a cardiac arrest and died.

In each case, the patient was shifted from one emergency room to another not for medical reasons, but for economic ones--the fear by the receiving hospital that it would not be paid for treating the patient.

Health care officials call such transfers hospital “dumping,” and it is a problem that is drawing increasing attention in California and across the nation.

Attention will be focused on the dumping issue Tuesday, when the state Assembly’s Health Committee meeting in Sacramento considers a bill that if enacted would give California one of the toughest “anti-dumping” laws in the nation.

“Lives are being lost every month this goes on,” said Assemblyman Burt Margolin (D-Los Angeles), who introduced the bill. “It is a violation of every code of ethical behavior one can imagine.”

The patients who are “dumped” are almost always the indigent, the uninsured and those on Medi-Cal. Hospitals are motivated to transfer them out of fear that the patients won’t be able to pay for their care or that the Medi-Cal payments won’t cover the hospital’s actual costs. In addition, some specialists, on call to back up the emergency room doctor, refuse to care for such patients.

The patients are usually transferred to public hospitals, where their unpaid bills are absorbed by local taxpayers.

The dumping problem has become more acute in recent years as competition among hospitals has increased and state and federal support for health care has been cut back. Margolin’s bill would supplement a federal “anti-dumping” law, approved by Congress March 20 as part of a deficit reduction measure and awaiting President Reagan’s signature. It details appropriate transfer procedures, mandates reporting of all violations and establishes stricter enforcement procedures.

The federal bill specifies civil penalties up to $25,000 per case against a hospital or doctor when patients are transferred inappropriately. Hospitals can be excluded from the Medicare program for violations.

Margolin’s bill, AB 3403, would require that all hospital emergency rooms in the state provide needed emergency treatment, regardless of the patient’s “insurance status, economic status or ability to pay.” A similar requirement would be imposed on individual doctors with hospital staff privileges.

Existing regulations specify these responsibilities, according to Margolin. But the possible penalties for abuses--a letter of reprimand or revoking the license of a doctor or an emergency room--are usually either too mild or too harsh, he said.

The Margolin bill would impose new penalties--including fines of up to $25,000 and jail terms of up to one year. A summary of all violations would be published quarterly by the state Department of Health Services and be available to the public.

The California Medical Assn. opposes the bill, according to a spokesman.

The California Hospital Assn. supports the “intent” of the Margolin bill, said C. Duane Dauner, its president, despite reservations about some of the provisions.

“Economic transfers are a way of life today,” according to Dauner, who characterizes dumping as just one symptom of a larger issue--providing medical care for the poor and uninsured.

The dumping problem was documented in a recently completed study by Lebo, the physician at the San Bernardino County Medical Center. It showed that in a three-month period last fall, 423 patients were transferred to the San Bernardino County Medical Center from other hospitals--91% for financial reasons. Of these patients, 31 were in unstable condition, including nine with stab wounds and three with gunshot wounds, Lebo said.

“The great majority of these patients were sent from hospitals that had the facilities to take care of them,” said Lebo, who declined to identify these hospitals.

One patient died during the study--a man in his 50’s, suffering from alcoholism, anemia and pneumonia. He stopped breathing in the ambulance after being declared stable for transfer by physicians at another hospital. “He might have survived if they had cared for him,” Lebo said.

Despite a regulation of the Joint Commission on the Accreditation of Hospitals that patients not be transferred until the receiving hospital has consented to the transfer, 40% of the transferred patients arrived unexpectedly.

“It is frustrating and exasperating,” said Dr. Francis Communale, the hospital’s medical director.

“Sometimes the receiving hospital would call up and we would tell them the hospital was full, but the patient would be sent to our emergency room anyway.”

Problems in 38 Cases

Even within Los Angeles County, which enacted widely praised transfer procedures in 1982, 87 inappropriate transfers were investigated between March, 1985, and February, 1986, according to Robert Karp, of the health facilities division of the county Department of Health Services. Problems were confirmed in 38 cases, he said.

Under Los Angeles County regulations, a medical alert center, staffed 24 hours a day at County-USC Medical Center, must approve all transfers from private hospitals based on guidelines developed in conjunction with the Hospital Council of Southern California.

Violations are reported by emergency room doctors to the county Department of Health Services for investigation. If neglect or abuse is found, the offending hospital is contacted and asked to submit a plan to correct the problem.

In the last year, five cases were also sent to the state Board of Medical Quality Assurance, which licenses physicians, according to Karp.

The county system is credited with cutting the number of inappropriate transfers by more than half, according to Geraldine Dallek, of the National Health Law Program in Los Angeles, who has investigated the issue. Of about 80 transfers arriving each day at County-USC Medical Center, more than 90% receive prior approval and meet all protocol requirements, she said.

But a National Health Law Program study also pointed out the county system’s weaknesses. “Hospitals which violate transfer provisions know that the penalty for doing so is light,” it concluded. “The county has no authority to fine a hospital and the likelihood of a license revocation is almost nil.”

A National Trend

The California bill reflects a national trend toward legislation to ensure that the poor receive adequate emergency care. In addition to the federal bill, both South Carolina and Texas enacted tough “anti-dumping” laws in 1985. Alameda County is preparing transfer procedures similar to those in Los Angeles County.

The California Hospital Assn., however, asserted that the larger issue of so-called “uncompensated care,” must be tackled as well. Uncompensated care exceeds $1 billion out of the more than $12 billion spent on hospital care in the state each year, the association’s Dauner estimated, with 12% of the hospitals bearing 60% of the burden.

To provide relief for these institutions, the hospital association has proposed the creation of a fund, to be jointly financed by the state and federal governments and the hospitals.

Supporters of Margolin’s bill, however, believe the transfer issue should be dealt with on its own terms. “I want to get the whole damn thing stopped,” said Lebo, who was on duty the night the patient stabbed in the heart died.