Private to Public ED Dumps Hurt Patients

Spoon Feed
Failure of private hospitals to care for the uninsured resulted in informal ED to ED referrals, which meant up to 20% increased volume in public EDs for certain diagnoses, particularly orthopedic issues.  This led to duplicate testing, increased cost, complications, delays in care, and poor treatment of the most vulnerable patients.

Why does this matter?
EMTALA was purposefully written to be vague since not every possible medical scenario can be encompassed in this unusually short federal law.  As a result, the Circuit Courts have interpreted EMTALA differently with no unified legal theory to guide emergency physicians and hospitals.  Offering some clarity, CMS issued interpretive guidelines stating that "[h]ospitals may not attempt to coerce individuals into making judgments against their best interest by informing them that they will have to pay for their care if they remain, but that their care will be free or at low cost if they transfer to another hospital."  CMS was explicitly trying to prevent both direct and indirect referrals to public EDs.  But what actually happens to uninsured patients when they show up in some private EDs? Sadly, it's not pretty.

Kickin' the can down the road
In a 10 week period, 143 patients presenting to a public ED were prospectively identified as having already been seen in outside ED's for the same chief complaint. This resulted in 73% receiving the same tests.  94% were uninsured; 27% required admission; 61% had fractures; and 95% who were able to be discharged still needed outpatient follow up for their condition.  53% were told to come to the public ED by the initial ED, and 23% were referred to the public ED from the specialist's outpatient office.  Among those patients referred from a private ED to the public ED, 65.8% were referred by a local nonprofit ED. 

About half of the patients completed a survey, and 23 were qualitatively interviewed.  Interviews revealed, "concerns about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow-up care without insurance, loss of work, and financial strain."  The public ED reported a, "severe safety concern due to delay in care," in 6% of patients.  In summary, patients are being subjected to duplicate testing, excessive radiation exposure, rude treatment, delays in care, unnecessary financial strain, and risk to their health because some private hospitals choose not to continue care for uninsured patients seen in their facilities—even if the affiliated hospital is nonprofit.

Source
"What Do People Do If They Don't Have Insurance?": ED-to-ED Referrals. Acad Emerg Med. 2018 Jan;25(1):6-14. doi: 10.1111/acem.13301. Epub 2017 Oct 4.

Co-authored by Clay Smith and Thomas Davis.

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