Hospital Law Awaits Tattletales : Patient ‘Dumping’ Angers Officials

Some San Diego hospitals, which have long suspected that other medical facilities steer uninsured pregnant women who have not received prenatal care to their doorsteps, are looking toward a new state law as a long-term solution to overcrowded maternity wards and financial losses that result from that practice.

Senate Bill 12, which took effect Jan. 1, prohibits “patient dumping” by hospitals and medical facilities and allows the state Department of Health Services to fine hospitals and doctors who engage in the practice. It also requires emergency room personnel who believe they have received a dumped patient to investigate and report the incident or face a fine themselves.

Passage of the law has started a curious waiting game among officials of some hospitals with obstetrics units and advocates for women who have been the victims of patient dumping: Everyone is wondering which hospital will become the first to accuse another facility of dumping and test the new law.

Finger Pointer?

“It appears that we’re playing a cat-and-mouse waiting game to find out who will point the first finger and say this is an inappropriate transfer,” said Kim Warma, director of the independent Regional Perinatal System and an advocate for increased prenatal care to low-income women.

“I don’t know what they’re waiting for,” she said. “It’s not like this hasn’t happened. We’re all just waiting to see who’ll do it first.”

Though there are almost no statistics to confirm allegations that women about to deliver babies have been dumped, some medical officials are convinced that it occurs regularly. According to them, pregnant women--most of them undocumented immigrants or Mexicans who cross the border to deliver their children on American soil--show up at hospital emergency rooms when they believe they are in labor.

The hospitals, unwilling to take in mothers who have received no prenatal care and to absorb the high costs of caring for indigent women, “dump” the women to other hospitals, sometimes going so far as directing them there or providing maps.

Besides creating a potential danger to a woman and child turned away from a hospital, dumping angers physicians at hospitals saddled with unexpected deliveries, which tax the already overcrowded maternity wards and can cost them thousands of dollars in services for which they will not be paid.

At UCSD, which according to Warma is receiving an increasing disproportion of “no care” mothers, medical authorities are convinced that many of the walk-ins at their emergency rooms have been steered there by other hospitals. While many expectant mothers come to UCSD because of an informal grapevine, some clearly have been told to go to the Hillcrest hospital, said Dr. Thomas Key, director of perinatal medicine at UCSD.

“Increasingly over the past few years, we have received patients who have been at a variety of different institutions, who came to us with map in hand and instructions about where to go,” Key said.

Sharp Memorial Hospital emergency room physicians experienced the same thing several times last year, said Jan Stichler, director of the Women’s Center there. “I know for a fact that it was another hospital” that sent the patients because of the markings on the maps, Stichler said. “And not only that, but the patient will tell you where (she) has been.”

Added Warma: “All you have to do is look at the no-care rate and see that there’s a really disproportionate rate at certain hospitals, and I don’t know why. It’s not like one hospital is that much more difficult to get to than another.”

Target Hospitals

Figures compiled by Warma’s agency show that UCSD--where no-cares sometimes compose more than 25% of the monthly total of deliveries--Tri-City Medical Center in Oceanside and Scripps Memorial Hospital in Chula Vista as the three top recipients of no-care mothers, with the numbers ranging from 25 to 100 patients a month. There are 13 hospitals in San Diego County with obstetrics units.

But there are those who say they see scant evidence to support dumping allegations. Paul Simms, deputy director of physical health services for the county Department of Health Services, said he hears of three or four cases of dumping each year. The accounts are anecdotal, not formal complaints, he said.

Ernie Trujillo, district administrator for licensing and certification for the State Department of Health Services, said his office receives about five complaints of patient dumping each year in San Diego and Imperial counties, of which one or two concern obstetrical patients.

Shirley Walters, assistant administrator at Scripps Memorial Hospital in Chula Vista, said, “Quite frankly, I don’t think that there’s that much dumping going on, at least in the South Bay. Walters’ hospital is the only one south of National City with an obstetrics unit.

The new law, which was designed to prevent dumping of all kinds of patients--particularly trauma cases--may provide clues as to which side is correct. It requires hospitals to monitor all their emergency room patients, and to file a report with Trujillo’s office if they suspect a patient has been dumped on them. Failure to do so can cost the hospital receiving the patient a $10,000 fine.

At UCSD, which has been conducting such monitoring since last August, Key said, “It’s a surprise to me that we’ve not seen the right case yet. It’s already a month and a half (since the new law took effect), and still the problems continue. I would speculate that either people are being a little more cautious than they have been or . . . we’ll see three (dumps) next week.”

‘Deterrent Effect’

If hospitals already are being more careful, the law is working.

“The main impact of this, we hope, will be a deterrent effect that results in no inappropriate transfers,” said George Cate, associate director of government relations for the California Medical Assn., which supported the legislation sponsored by Senate Republican leader Ken Maddy of Fresno. “We don’t want people to be fined. We want this to stop.”

The bill threatens hospitals engaging in dumping with a $25,000 fine for each incident and doctors involved with $5,000 fines. The state Department of Health Services’ certification and licensing division is responsible for investigating complaints.

Since similar federal legislation took effect in August, 1986, 32 complaints of dumping have been received statewide, said Lawrence McDonough, associate regional administrator for the federal Health Care Financing Administration. Of the 23 cases fully investigated so far, three violations have been found, and one facility has paid a $125,000 fine.

The state law is expected to yield many more cases because hospitals receiving dumped patients are required to report it and because state emergency rooms are now required to post signs telling their 7.1 million annual visitors how and where to file complaints, health authorities said.

But because of the wording of the section of the law regarding obstetric cases, there is debate over whether the new law actually will help stop patient dumping in those kinds of cases.

The law prohibits transferring women who are in “active labor,” defining that term to mean that “there is inadequate time to effect safe transfer to another hospital prior to delivery” or “a transfer may pose a threat to the health and safety of the patient or the unborn child.”

Some medical authorities believe that will help instill a sense of responsibility among hospital workers who may have previously turned away a patient.

‘Think It Will Help’

“I think it will help,” said Stichler, the Sharp Memorial official. “I think the hospitals will understand the seriousness and the intent of this law. Certainly, the hospitals will not want to be caught in breach of that law.”

“I think it will make people more aware that we have an equal share issue here,” Warma said. “I think it’s a move in the right direction. But I think the state has to recognize that the problem is much greater than just inappropriate transfers.”

Others are less sure. Key, whose hospital stands to be the top beneficiary of an end to dumping, said UCSD will gain no advantage from the law for several years--until after a lawsuit brings the issue into the courts and a judge or jury defines active labor.

Interpretations of active labor will vary from hospital to hospital, Key said, and therefore it will be very difficult to say definitively that a patient has been dumped in all but the most extreme circumstances.

In the near future, UCSD will be making its criteria for obstetric admissions more conservative to lessen severe overcrowding in maternity wards, he said. The new law will deter the hospital.