Treat, don’t dump,’ regulators say

Feds expand definition of patient-dumping’

Dotting your I’s and crossing your T’s could pay off — by avoiding fines of up to $50,000 per incident. That’s because federal regulators announced in late November that they will use the "patient-dumping" prohibition from an existing section of the Social Security Act to ensure immediate care whether or not a patient’s insurance pays.

The proposed guidelines, called the Federal Patient Anti-Dumping Statute, were published in the Dec. 7, 1998, Federal Register.1 Following a 30-day public comment period, a final special advisory bulletin will be published. (For a copy of the proposed guidelines, see insert.)

The guidelines were issued as a result of rising concern about the already illegal and unethical practice known as patient-dumping, whereby seriously ill or injured patients are transferred to other hospitals or care is delayed because of the patients’ lack of insurance.

Managed care patients at risk

Particularly vulnerable to this type of situation are patients enrolled in managed care plans, says U.S. Inspector General June Gibbs Brown. The plans often require hospitals or the patients themselves to obtain prior authorization for certain medical procedures or hospitalization.

"Anyone who believes they are experiencing a medical emergency — regardless of their ability to pay or the kind of insurance they have — has a right to expect that hospitals and physicians will meet their obligations under federal law to provide a required emergency medical screening and stabilizing care," announced Nancy Ann DeParle, administrator of the Health Care Finan cing Administration in Baltimore.

"We will be vigilant in ensuring that hospitals and physicians fulfill their obligations," she said in announcing the proposed statute.

While bureaucrats were announcing proposed guidelines to curb the patient-dumping problems, the Supreme Court was hearing about the effects of patient dumping firsthand. The guardian of a poor and uninsured patient is seeking $10 million in damages from the University of Louisville (KY) hospital. The patient has no memory of being hit by a truck, admitted to the hospital, or suffering from repeated bouts of pneumonia and infections. Two months later, she was transferred to a nursing home in Indianapolis. The lawsuit alleges she was dumped because she was poor, uninsured, and her bill had reached $393,000.

For ethics committees, the proposed guidelines add ammunition to existing policies and procedures regarding medical treatment for all patients. The announcement also serves as a reminder to examine existing contracts with managed care plans to determine if revisions are necessary.

Gray areas remain

Although clarification in the law is welcome, it may not solve all the problems associated with delayed treatment or care, says Rick Wade, spokesman for the American Hospital Associa tion’s Washington, DC, office. "It’s not going to solve the problem of some plans deciding that they’ll use preauthorization rules as a way not to pay hospitals," he adds.

Another potential gray area of the proposed guidelines is hospitals getting stuck with unpaid bills from managed care plans. Under the new government guidelines, hospitals must examine and stabilize every patient who walks in the door. Many health plans, for example, will not pay if parents take a sick child to the emergency department without first checking with the physician or calling a nurse-managed telephone service.

Once a patient enters the emergency department, the hospital’s staff can’t delay care while employees inquire about insurance or check with a health plan for authorization — even when urgent treatment does not seem necessary.

"We want to make sure patients are seeking care in the most appropriate setting," says Karen Ignagni, president of the Washington, DC-based American Association of Health Plans, which represents insurers covering more than 150 million Americans.

"That means not going to the hospital just because it’s the most convenient place to seek treatment on a weekend or after hours," Ignagni adds.

Reference

1. 63 Fed Reg 67,486 (Dec. 7, 1998).