10% of ERs Rejected Patients, Study Finds

Hundreds of hospitals around the country have violated a 15-year-old federal law that requires them to provide emergency care to anyone, regardless of ability to pay, according to a federal survey of emergency room workers and a consumer group’s report released Thursday.

Government investigative files reviewed by the group, Public Citizen, showed that more than 500 hospitals, including 77 in California, were cited by the federal government from 1997 through 1999. That amounts to about 10% of the nation’s hospitals.

Additional files reviewed by The Times showed that 47 of about 500 California hospitals were cited for later violations, mostly in 2000.

Turning away such vulnerable patients is “a national disgrace,” said Dr. Sidney Wolfe, medical director of Public Citizen, which was founded 30 years ago by consumer activist Ralph Nader.

Wolfe called for an increase in seldom-imposed fines, which now top out at $50,000--a sum so low, he said, that “it’s almost an open invitation to American hospitals to violate the patient-dumping law.”

Alicia Mitchell, spokeswoman for the American Hospital Assn., countered that the report “highlights the exception, not the rule.” She said American hospitals provided $20 billion in uncompensated care in 1999, the last year for which data are available.

Federal law requires hospitals to screen without delay all emergency room patients by giving them examinations and tests to make diagnoses. Hospitals must also try to stabilize patients by using doctors who are on hand or on call.

If patients cannot be stabilized, hospitals generally are free to transfer them to more sophisticated medical centers, which are required to accept them.

The law means that hospitals and on-call physicians must provide services first and worry about payment later. They are not allowed, for example, to delay a screening until they have determined how a patient will pay.

But that did not stop the Kaiser Foundation Hospital in Bellflower from refusing to care for a man who arrived by ambulance after a traffic accident in 1999, according to federal documents cited by Public Citizen. He was told he would have to pay $75 before a nurse or doctor looked at him, since he was not a Kaiser member.

Similarly, at Coastal Communities Hospital in Santa Ana in 1997, a man who was having a heart attack went to the emergency room but was told to go elsewhere because the hospital did not have a contract with his HMO, documents show.

And New York’s St. Luke’s-Roosevelt Hospital in 1999 told uninsured patients that they would have to pay a fee of at least $400, the consumer agency’s report said. According to government documents, patients would simply leave.

Spokesmen Call the Incidents Isolated

Spokesmen for all three hospitals said that the incidents were isolated and that the problems that produced them have been corrected. In fact, almost all of the hospitals cited since the law was passed have filed plans of correction, as they were required to do to maintain eligibility for Medicare reimbursements. Only six hospitals lost Medicare eligibility when they did not fix cited problems.

It is difficult to say precisely how widespread patient dumping is. There are, however, some indicators.

More than one in five of the nation’s roughly 5,000 hospitals have been cited for violations since the anti-dumping law passed in 1986. More than 100 have been cited more than once.

Wolfe said he believes this is just the tip of the iceberg, because most victims of violations do not complain.

A spokeswoman for the federal agency that issues the citations noted that the number peaked in 1994 at 465. That year the federal Centers for Medicare and Medicaid Services adopted regulations that clarified the law. Since then, citations have ranged from 180 to 210 annually.

A federal hospital survey published this year suggests that many facilities screen patients for their insurers’ ability to pay--a practice that is legal unless it results in delays.

According to the survey of 100 hospitals by the U.S. Department of Health and Human Services, one in every three hospitals reported that it routinely contacts health plans to authorize screening examinations. And one in four said it routinely asks health plans to authorize stabilizing treatment.

Of the hospitals that seek authorizations, 10% to 15% do not screen or treat patients if health plans deny the authorizations, staff members reported. That would be unlawful.

Hospitals that do not have the medical resources to help emergency patients may transfer them to hospitals that do. And the hospitals with resources are compelled to accept them.

That’s why Cedars-Sinai Medical Center in Los Angeles was cited in late 1997. Federal officials found that an emergency room doctor had refused to accept the transfer of a brain-injured patient from a hospital that did not have access to a neurosurgeon, even though Cedars had a neurosurgeon available. Cedars reported itself to the government, according to the federal report cited by Public Citizen.

The patient, who apparently had no health insurance, had to wait three hours while a doctor arranged his transfer to a public hospital.

Specialists Required to Be Available

Hospitals with emergency departments are required by law to have specialists on call who must respond to emergency requests to stabilize a patient.

But many specialists are reluctant to be on call because there is a good chance they won’t be paid, said a Health and Human Services report this year citing research by the California Medical Assn. and other groups. This is especially true in areas with large numbers of uninsured residents and high rates of participation in HMOs.

Sometimes, even physicians who have agreed to be on call refuse to appear, either because they will not be paid or for other reasons.

At Mercy Medical Center in Merced, Calif. in late 1998, in an incident the hospital voluntarily reported to regulators, an on-call surgeon refused to report to the emergency room to help treat a 49-year-old mentally retarded man who was gravely ill. The surgeon remarked that “no one would miss [the man] if he died,” according to documents cited by Public Citizen.

After repeated urgings by staff, the doctor did appear, but it was too late. The man died that night.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

To File Complaint

To file a complaint about the denial of emergency room treatment, contact:

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Centers for Medicare and Medicaid Services

75 Hawthorne St., 4th floor

San Francisco, CA 94105

(415) 744-3501

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For a list of hospitals cited in report: www.citizen.org/QuestionableHospitals/

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Times staff writer Peter Gosselin contributed to this story.