The term “patient dumping” refers to certain practices some healthcare providers use to remove uninsured or lower income patients from their facility. These include discharging patients prematurely or refusing to care for them at all to reduce the inherent financial risk their treatment represents.
While we may like to believe that “patient dumping” is a relatively new practice developed and employed by providers already operating on razor thin margins looking for a way to stay financially viable, the truth is that has been around since the late 1800s. In fact, the term was supposedly coined in New York when it was reported that private hospitals were sending poor patients to that city’s main public hospital. Making the situation worse was that these patients, who were transported by horse-drawn ambulances, often died while being transferred. This situation resulted in the first legislative attempt in 1907 to prohibit the practice.
When the Emergency Medical Treatment and Labor Act (EMTALA) was enacted more than 35 years ago, it was supposed to put an end to “patient dumping.” One provision of this act provides for stiff fines as well as possibly having Medicare provider agreements suspended for violations. The logic here, of course, is that any unreimbursed expenses generated by these patients would pale in comparison to hefty fines and/or loss or Medicare reimbursement.
Most hospitals have policies against “patient dumping,” and over the years have implemented a variety of policies and procedures to address the issue. Nonetheless, this practice unfortunately continues. While approximately four percent of hospitals receive EMTALA citations in any given year, this translates, by some accounts, into roughly 4,000 individual violations. Not an insignificant number when you consider that each violation may represent multiple patients.
Consider these recent well-publicized cases of alleged “patient dumping” across the country:
- Seniors still in hospital gowns and wearing hospital no-slip socks were found on the streets with nowhere to go and often unsure of how to take the medications they were given at discharge
- A disabled man with schizophrenia was discharged and sent to a group home where he subsequently stopped taking his medications and was found living in squalor
- A deceased man dressed in a hospital gown and in a wheelchair was found on the street by a passersby
- A young female patient in a hospital gown and socks was escorted out of a hospital and then left alone at a bus stop in freezing temperatures
These violations clearly put patient and community health at risk. They may also exacerbate the very problem that providers who engage in “patient dumping” hope to avoid since many of these patients may simply boomerang back to the ED with even more complex medical problems than those they had originally presented with.
These examples also send the message that “dumped” patients are not as valued or treated as well as housed patients or those with insurance and/or greater means. This perception, of course, is counter to a provider’s responsibility to its community and commitment to protect its members’ health. Supporting this message and perception is a study published by JAMA Internal Medicine that showed that uninsured patients were more likely to be discharged from the ED and/or to be transferred to another hospital. The researchers concluded the study confirmed the unfortunate belief that financial incentives may be associated with decisions about hospitalization.
Building on the EMTALA, various jurisdictions also require providers to have policies in place for managing the discharge of the unhoused. Unhoused or homeless patients present a special challenge since finding them shelter may be difficult. This group may also have a disproportionate number of patients suffering from a variety of medical conditions which could increase the potential for health and safety risks if they are summarily “dumped” on to the streets. It also is important to remember that a patient usually has the right to accept or decline any resources offered to them upon discharge.
The entire industry suffers significant damage to its reputation, and to patient confidence in healthcare in general, given that dumping cases can readily become local and even national causes célèbres that serve to only highlight the underbelly of the industry.
What Providers Can and Should be Doing
One reason given for the ongoing violations of EMTALA is that staff may simply not fully understand its provisions and how to comply with them. On paper, these provisions are quite direct:
- Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to ask about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment.
- If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an “appropriate” transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.
- Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.
So, one thing providers can immediately do is review their current EMTALA training programs and update them if necessary to ensure staff understanding and compliance.
One solution proposed by experts studying the dumping issue is universal health care. Since that is not about to happen soon in the United States, providers should place renewed efforts on examining policies and procedures in place for discharging the unhoused to better address their special needs and challenges. This could include identifying and contracting with various community resources that may provide housing to such patients. Providers can readily work with community organizations to create such support programs.Researchers point out that having these in place could reduce rehospitalization rates by helping to ensure the unhoused and underserved have appropriate shelter/living situations to continue recuperating.
Given that one study reported that homeless patients had a 22 percent higher hospital readmittance rate than insured patients, supporting their recuperation could help address one cause of “dumping”. They also can develop internal resources, such as a closet with donated clothing for patients being discharged.
While the causes of motivations for prematurely discharging patients are admittedly complex and challenging, literally dumping patients on the street is never the solution. Discouraging this practice and working together as an industry to stop it benefits everyone – providers and their communities alike. It also is the right and moral thing to do.