'Patient Dumping’ Still a Problem Despite Law
A sweeping new analysis indicates a federal law designed to prevent hospital "patient dumping" and ensure equal access to emergency medical care is falling short.
Researchers from Yale University and elsewhere analyzed 215,028 emergency department visits to 160 hospitals for pneumonia, asthma and chronic obstructive pulmonary disease in 2015.
After being stabilized, patients who were uninsured or covered by Medicaid were more likely to be transferred to another hospital than privately insured patients. Uninsured patients also were "markedly" more likely to be discharged from the emergency department, according to the study, published Monday in JAMA Internal Medicine.
The results "confirm the belief that financial incentives, or a patient's ability to pay, may be associated with hospitalization decisions," researchers wrote. They adjusted for factors such as patient age, sex, income and health conditions in an effort to eliminate bias in the results.
The findings indicate that more than three decades after the Emergency Medical Treatment and Active Labor Act took effect, lower-income patients still face unequal treatment in emergency care settings. The law requires hospitals to screen anyone who comes into their emergency department and stabilize anyone with an emergency medical condition, regardless of citizenship status, insurance status or ability to pay.
The law was enacted in 1986 amid concern that hospitals were "patient dumping," or discharging people before they'd been stabilized and denying care to poor patients with medical emergencies. Its requirements have fed into the debate over whether government-provided universal health coverage is necessary, since everyone has access to care in a true medical emergency.
But the new research indicates the decision to transfer lower-income patients to other facilities – reducing the chance a hospital will not be paid for providing care – means hospitals can technically meet the law's requirements without meaningfully helping patients who need inpatient hospital care. Notably, patients severely ill from pneumonia, COPD or asthma "can generally be cared for in hospitals with standard intensive care capabilities," researchers say, so transfers to other facilities may not meet the law's threshold for "appropriate" transfers.
"By restricting this analysis to hospitals capable of providing critical care for patients with pulmonary conditions, we were less prone to incorrectly identifying medically necessary transfers as financially motivated," the study says.
A survey conducted by researchers showed how the decision to transfer patients to other hospitals from the emergency department unfolds by hospital ownership status. Using a smaller sample of hospitals and patients, researchers found that compared with privately insured patients, uninsured patients were more likely to be transferred from for-profit hospitals and less likely to be transferred from nonprofit hospitals, though researchers said further study is needed to confirm those conclusions.
"Policymakers should broaden the scope of hospital quality, payment, and certification initiatives to reduce these disparities and improve access to hospital-based care," study authors wrote.
Addressing the gap in insurance coverage and ensuring access to non-emergency care would be the surest way to improve the U.S. health care system, Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, and Dr. Eric Wei, the health system's vice president and chief quality officer, wrote in a commentary accompanying the research.
There is no equivalent mandate in the U.S. to provide medically necessary non-emergency care, they note, which may force patients with chronic conditions like diabetes or hypertension to wait until their conditions become an emergency to seek care and contribute to worse health outcomes.
"Providing universal health insurance would improve the health of uninsured persons, reduce unnecessary emergency care, and strengthen the health care system in the United States," Katz and Wei wrote.
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