Transferring Uninsured Patients To Another Hospital.

I have always had a strong sense that some critical access hospitals were more likely to transfer uninsured or under insured patients to regional referral centers than they would for patients who had higher paying third party insurance.  Intriguing research published in  the June 11, 2012 Archives of Internal Medicine suggests some hospitals may be doing just that.  And it's all EMTALA compliant on the surface.  Shocker.  Huh?  Drs David P. Kao, Marina Martin, Amar Das and Stephen Ruoss detailed their findings in a research letter titled  Consequences of Federal Patient Transfer Regulations:  Consequences of Federal Patient Transfer Regulations: Effect of the 2003 EMTALA Revision on a Tertiary Referral Center and Evidence of Possible Misuse.  Click on this link to read the whole study.  It is a fascinating look at the unintended consequences of unfunded government mandates.  I say, unintended, but in fact,  I  would expect this to be the default path as hospitals and doctors apply  liberal use of the rules to maximize the business side of their practice as it appears to be legal at face value.

EMTALA stands for Emergency Medical Treatment and Active Labor Act.  This act requires ED physicians to stabilize all patients regardless of ability to pay and hospitals must then provide additional necessary physician specialty care or transfer the patient to a facility that can provide such care when specialist care is not available. In other words, if the patient needs a gatroenterologist and no GI doctor is on call, the ER is obligated to transfer the patient to a hospital that can provide such care.   According to these physicians, many community hospitals have had a difficult time finding physicians to provide coverage for specialty care, as a result of EMTALA regulations (another expected unintended consequence).  These physicians note that CMS published a "Final Rule" in September 2003 that allowed hospitals with EDs not be required to guarantee specialist coverage at all times and even allowed doctors to take elective call (not being required to see ED patients).

With that ruling in mind, what these physicians did was genius.  They compared EMTALA transfers into their large tertiary medical center (Standford University [SUH] in Standford, California) from surrounding community hospitals both before and after 2003 and they looked for patterns incorporating rates of transfer for uninsured or underinsured  patients before and after this September 2003 EMTALA Final Rule.  Why did they do this?  If hospitals were not required to have specialty care at all times, transferring hospitals, after 2003, could use "transfer for specialty care" as an acceptable reason for transfer.  No insurance is not an acceptable reason for transfer.  Claiming you can't take care of the patient is.  These doctors wanted to know if the rates of transfer before and after the legal "out" in 2003 changed.  

They reviewed all transfer data into SUH from 2000 through 2008.   During that period, a total of 10,584 were subject to EMTALA regulations.    They discovered that the number of underinsured and uninsured patients increased significantly  from about 25% before 2003 to 32% after 2003.  That's a 28% increase in transfers after the 2003 ruling was implemented.    But the data doesn't stop there.  The most common reason underinsured or uninsured patients were transferred was for gastrointestinal bleeding (I can only assume this is from underinsured or uninsured alcoholics with associated GI track pathology).  Underinsurance  in admissions for primary alcoholic related diseases is my clinical experience too.

While the rates of transfers varied widely among referring community hospitals, several hospitals showed a potential pattern of EMTALA misuse based on insurance status.  Despite the rise in transfers to tertiary referral centers for care not available at their institution, the data suggested that was simply not the case.  In fact, in studying data from one compelling hospital, they noted a large increase in the number of endoscopic procedures being performed locally at one hospital after 2003 (200% increase in 2004 compared with 2000-2003),  while also admitting fewer uninsured or underinsured patients to their hospital in the setting of a dramatic increase in EMTALA transfers to SUH for gastrointestinal bleeding.  What was the most common reason cited for transfer of these patients needing endoscopic work up?  Lack of an on call gastroenterologist available (in nearly all transfers of this population).  How can a hospital double their endoscopy program in one year while claiming not to have access to gastroenterologists? Is there a real lack of access when all these bleeders come to the ER?  Or is it the lack of adequate insurance.

On the surface and under the blankets, and even if you lift up the mattress to look for an alternative explanation, the only possible explanation I can see is some hospitals are legally  transferring underinsured patients to tertiary referral centers for financial reasons when their own data suggests they are capable of providing the service locally if they chose to do so.  This is not unexpected.  This is just another in a long line of expected unintended consequences of government intervention.  

Unfortunately, eventually even large tertiary hospital systems will start losing access to specialty care in the ER as community hospitals send a disproportionate number of their underinsured patients to the ER while keeping the good paying ones at home.  In fact, I've already seen it with some specialties and it's only going to get worse as physicians continue to leave inpatient medicine for the lifestyle and controlled environment of outpatient clinical medicine and over night ASC admissions that pay much better on a time and effort axis and that can  guarantee a better payer mix.

And just in time for ObamaCare to annihilate the disproportionate share dollars being paid to hospitals by Medicare to care for under insured patients.  Everyone may be insured.  They'll just be underinsured and the community hospitals will continue to send these folks to big hospitals who will find it difficult to absorb the rapid deterioration in their payer mix.   The sad thing about his research?  Ask any practicing hospitalist and they'll tell you no research is necessary.  We see this everyday.  Why would any physician want to work for free.  I know of no other situation where non medical trades expect to put in their hours and not get paid.  How many patients show up to work and expect to work for free, every day.  Here's an original Happy Hospitalist crude medical ecard that sums up the issues quite nicely.

"Some patients are transferred to other hospitals because they needy a higher level of care."

Transfer due to needy a higher level of care ecard humor

What the accepting physician REALLY wants to say:

What the accepting physician REALLY wants to say

Some of this post contains humor that may only be understood by some healthcare professionals. Read at your own risk.

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