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Hospital sends undocumented, uninsured immigrant home for care, wins civil suit
Patient reportedly wanted to go home, but guardian resisted plan
What is a hospital to do when it has already invested in care for an undocumented, uninsured immigrant who has a traumatic brain injury? One hospital in Florida decided to send the patient back to his home country of Guatemala, saying it was fulfilling the patient's wishes even though critics argued that it was only trying to get the man's home country to foot the bill.
That set off a legal storm that holds lessons for risk managers who may find themselves in a similar quandary, considering the same idea or responding to pressures from hospital executives who want to lower the costs of indigent care. The experience of Martin Memorial Medical Center in Stuart, FL, suggests that effectively deporting the patient will stir up a hornet's nest of controversy and bad publicity. According to the results of this case, at least, a health care provider may not legally be allowed to send the patient away, but it also might not suffer any civil repercussions.
The legal wrangling only recently came to an end after the July 2003 incident when Martin Memorial Medical Center chartered a private plane and sent Luis Jimenez back to Guatemala. His cousin and legal guardian, Montejo Gaspar, knew about the hospital's intentions and was trying to find a legal way to stop the move, says Anastasia Tonello, JD, partner and head of U.S. practice with Laura Devine Attorneys in New York City, who studied the case and provided analysis to Healthcare Risk Management.
Tonello says the case illustrates the difficulties hospitals face with illegal immigrants, but it also shows how the decisions of the health care provider can have far-reaching implications.
"The hospital argued that it had valid reasons to want to send this man back to Guatemala, but the repercussions for Jimenez are quite serious," she says. "And in the process, the hospital suffered some bad publicity and criticism."
Court documents indicate the 37-year-old patient had been in a vegetative state for more than a year and the hospital had spent more than $1.5 million on his care over three years, says Tonello. The records indicate that Gaspar, his legal guardian, initially supported Jimenez's return to Guatemala, but then changed his mind, Tonello says.
Tonello explains that the hospital obtained approval for the move from a county judge, but then Gaspar sought an emergency order to stop the move. Gaspar eventually won his appeal when a court ruled that a state judge doesn't have the power to decide immigration cases, Tonello says, but by then, Jimenez was in Guatemala.
"The guardian then filed a lawsuit against the hospital seeking nearly $1 million to cover the estimated lifetime costs of his care in Guatemala," as well as damages for the hospital's alleged "false imprisonment" of his cousin, Tonello says. A jury recently sided with the hospital, denying Gaspar's claim.
In a statement provided following the verdict by Martin Memorial Health Systems, Mark E. Robitaille, president and CEO says, "We are obviously pleased with the jury's decision. We have maintained all along that we acted correctly and, most importantly, in the best interests of Mr. Jimenez."
"Regardless of the outcome of this case, what is most disappointing is that the issue of providing health care to undocumented immigrants remains unresolved on a state and national level," the statement continues. "This is not simply an issue facing Martin Memorial. It is a critical dilemma facing health care providers across Florida and across the United States."
Robitaille says in the statement, "This has been a challenging situation for Martin Memorial for most of this decade, and we have spent a significant amount of resources as a result resources that could have been used to provide patient care. However, our hope is that something positive can come as a result."
Robitaille says the resolution of the case represents an opportunity for leaders at the state and federal levels to find a solution, rather than relying on individual health care providers to develop solutions on a case-by-case basis.
"Unfortunately, none of the proposed national health care reform bills currently being debated in Washington address the issue of how to adequately provide health care for undocumented immigrants in a way that is fair and equitable to everyone involved," Robitaille continues in the statement. "That means there are still cases like Luis Jimenez's in hospitals across the country and there will continue to be cases like Luis Jimenez's. Until the issue of providing care for undocumented immigrants is addressed, it will further impede the ability of our nation's hospitals to fully provide access to health care services for the communities they serve."
A hospital spokesman tells HRM that hospital officials do not have further comment beyond the statement issued by Robitaille.
Conflicting legal results
The legality and risks of such a transfer are not clear from the Florida case, Tonello says. On the one hand, the federal Court of Appeals in Florida determined that the trial court did not have the jurisdiction to authorize the transfer out of the country because immigration issues are the responsibility of the federal courts, according to Tonello.
"There's a huge issue, because the trial court went well beyond its authority, acting on a federal deportation matter," Tonello says. "But because the jury found for the hospital in the civil suit, the family is not going to be able to recover any damages, and the patient can't come back in the country. So, for this patient, this is the end of the issue."
Tonello cautions risk managers not to focus only on the outcome of the civil suit. Though the Florida hospital prevailed in that case, the federal court clearly indicated that the process by which the hospital transferred the patient was flawed.
"Focusing only on the civil suit may provide the impression that the matter has been settled in the hospital's favor, but that's really not true," she says. "The emergency appeal was decided in favor of Jimenez, but it was too late to help him. And if he was undocumented, he will be unable to return."
Tonello points out that the issue of sending illegal immigrants to their home country has a lot in common with the perennial controversy over "dumping" homeless patients and others with nowhere to go. Hospitals in the Los Angeles area have been under fire in recent years for sending homeless patients to Skid Row, dropping them at shelters or simply on the sidewalk. Tonello notes that a hospital sending a patient out of the country could experience the same blow to its public image.
Patrick J. Hurd, JD, an attorney with LeclairRyan in Norfolk, VA, says that, unfortunately, the issues in the Jimenez case are neither unique nor limited to undocumented immigrants. Acute care hospitals face issues of safe discharge every day, he notes. Those involving uninsured patients who live alone, are homeless, or are far from home are particularly problematic. The South Florida case gained wide- spread media attention because of the heated debate over illegal immigration in general, and the costs of providing health care specifically. The controversial nature of the particular facts in that case notwithstanding, Hurd says hospitals must focus their policies and procedures on safe and effective discharge management, regardless of immigration status, country of origin, or other circumstances.
"The hospital in this case took the action it did not based on the fact that the patient was an undocumented immigrant, but because the patient was uninsured and no facility properly equipped to provide safe and effective post-acute hospital care would accept the patient transfer," he says. "Acute care hospitals are not equipped to provide the level of care over the long term that such a patient deserves."
Discharge planning must begin no later than the time of admission and often should start while a patient is being treated in the emergency department, Hurd says. Hospital case management staff, risk managers, and patient safety officers must communicate and coordinate among themselves and with the physicians and nurses caring for the patient, Hurd says. The care plan adopted must be viewed with an eye toward ultimate discharge/transfer.
Tonello urges risk managers to consider the serious ramifications of sending an illegal immigrant out of the country before suggesting or urging such a move. Once the patient leaves the country, he or she may not be able to return.
"If the government removes you, there may be means of appeal or ways to get back in the country, but if the person leaves in this manner and they have no legal status in the United States, they may not be able to come back in," she says. "I don't think hospitals should be in the practice of removing people from the country, and someone who is legally savvy could have a claim against the hospital for depriving them of due process. There is no guarantee that the next jury would reach the same conclusion as this one."
For more information on indigent care for illegal immigrants, contact:
Anastasia Tonello, JD, Partner and Head of U.S. Practice, Laura Devine Attorneys LLC, New York City. Telephone: (212) 661-5401. E-mail: email@example.com.
Patrick J. Hurd, JD, LeclairRyan, Norfolk, VA. Telephone: (757) 441-8931. E-mail: patrick.hurd @leclairryan.com.