Patient dumping: why are patients disposable?

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

A public uproar ensued when a video revealed hospital staff literally dumping a woman wearing only a gown and socks in frigid weather on the streets of Baltimore. Imamu Baraka, a psychotherapist, witnessed the incident and recorded it on his cellphone. In the video, we see Mr. Baraka questioning the security personnel about their activity, and then we see them silently walking away.

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Image description: a crumpled hospital gown is pictured on the edge of a concrete ledge. The background is a concrete sidewalk. Image source: Lynn Park/Flickr Creative Commons.

The fact that the public appeared to be surprised by this event was bewildering. Patient dumping is hardly a new phenomenon, and in fact, it should not come as a surprise that those being dumped in this fashion are predominately non-white, poor, homeless, mentally ill, uninsured, and drug users. So, what is patient dumping? It is when hospitals that are capable of providing necessary medical care fail to screen, treat, or appropriately transfer a patient, or alternatively, when they turn the patient away because of the patient’s inability to pay for services.

Hospitals have long relied on this tactic as a way to offset care for those patients who cannot cover their costs, and so the hospital then is not reimbursed—it is an economic profit-loss decision. But, this blog is not about blaming hospitals. It is about recognizing that patient dumping is a symptom of larger healthcare system and societal ills. Consider the following:

Thirty million people in the U.S. remain uninsured after Affordable Care Act (ACA) implementation. Forty million adults experience mental illness in a given year. 554,000 people in the U.S. are homeless. Forty-three million live in poverty. Every day, the opioid epidemic claims 175 lives. These many data points speak to the U.S.’ combined lack of healthcare and social safety nets. Filling those gaps alone could potentially avert patient dumping.

By default, public, not-for-profit hospitals are charged with caring for such vulnerable patients. In the era of value-based, pay-for-performance, and accountable care organization (ACO) reimbursement models, those hospitals consequently will struggle to meet Centers for Medicare & Medicaid Services quality care metrics.

Federal legislation such as the Hill-Burton Act and later the Emergency Medical Treatment and Labor Act (EMTALA) were instituted to address legal and ethical concerns about patient dumping. Signed in 1946 by President Truman, Hill-Burton directed hospitals to make services available to anyone living in the geographic region of the hospital and to provide care free of charge to those individuals unable to pay. Signed in 1986 by President Reagan, EMTALA was enacted to protect all individuals seeking treatment at Medicare-participating hospital emergency departments. In addition to federal statutes, states also have passed legislation requiring hospitals to provide care irrespective of ability to pay and require that patients be medically stable before transfer. Regrettably, federal and state laws have not performed as was intended. Statutes designed to prevent patient dumping are criticized for 1) having narrow and unclear definitions of what constitutes a medical emergency; 2) failing to clarify what it means to stabilize patients before a transfer; and 3) failing to adequately provide the means for monitoring and enforcement (Ansell & Schiff, 1987).

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Image description: An aerial photo of a medical waiting area shows rows of blue chairs, and three seated individuals dispersed throughout. Image source: Erwin Morales/Flickr Creative Commons.

It would seem that patient dumping is symptomatic of larger macroeconomic and macrosocial issues. What possible solutions exist?

Suppose we actually provided health care to everyone? The ACA has greatly expanded insurance coverage by extending Medicaid, but many people remain uninsured due to prohibitive costs. Imagine having access to health insurance that was not employment dependent. Imagine that people with mild, moderate, and severe mental illness received comprehensive health services. Imagine a system of care that recognized that social determinants of health profoundly influence health outcomes. Imagine having food assistance folded in as part of a medical treatment.

Suppose we eradicated poverty and homelessness? Imagine a time when people could actually support themselves and their families because they made a living wage. Imagine that support was available for people to simultaneously work and pay for childcare.

Suppose we actually utilized comprehensive discharge planning for patients? Imagine planning documents that were easy to read and comprehend because health literacy was important. Imagine patients understanding the medications they needed to take when they got home. Imagine that prior to discharge patients had appointments scheduled for follow-up visits and had the transportation in place to get them there. Imagine providing support visits for elderly patients to make sure they were living in decreased fall risk environments.

Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all provider-patient panels included a significant number of homeless, poor, mentally ill, and uninsured individuals. Imagine an equal, fair, and just distribution of medical care service to the underserved that lightened that specific expectation on under-represented minority physicians (URMs). We know that URM physicians bear a disproportionate burden of providing care for the most vulnerable patients. Such a burden might substantially constrain their ability to meet quality care metrics for reimbursement.

Patient dumping is a harsh, cruel response to a healthcare and social system that can also be harsh and cruel. The goal for the U.S. healthcare system is to “ensure that every patient is a wanted patient regardless of ability to pay”.

Incidents of patient dumping such as the one recorded in Baltimore should not be cause for public consternation. The public protestation should instead be about macro-level systems and social ills that make such responses unsurprising. The above suppositions are probably wild-eyed idealist notions. But for a moment, just suppose they weren’t?

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 9, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Kelly-Blake: Incarcerated AND Sick: At Risk for Pain, Injury, and DeathWhite Horse, White Faces: The Decriminalization of Heroin AddictionRacism and the Public’s Health: Whose Lives Matter?Concussion in the NFL: A Case for Shared Decision-Making?

References

  1. Abel E. Patient Dumping in New York City, 1877–1917. American Journal of Public Health.2011 May;101(5):789-95. doi: 10.2105/AJPH.2010.300005. PMID: 21421951. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2010.300005
  2. Ansell DA, Schiff RL. Patient Dumping: Status, Implications, and Policy Recommendations. JAMA. 1987;257(11):1500–1502. doi:10.1001/jama.1987.03390110076030. https://jamanetwork.com/journals/jama/fullarticle/365084.
  3. Benedict K. Estimating the Number of Homeless in America: Statistics Show that America’s Homeless Problem is Getting Worse. The DataFace. January 21, 2018. Accessed July 6, 2018. http://thedataface.com/2018/01/public-health/american-homelessness.
  4. Center for Poverty Research University of California, Davis. What is the current poverty rate in the United States?. December 12, 2017. Accessed July 6, 2018. https://poverty.ucdavis.edu/faq/what-current-poverty-rate-united-states.
  5. Dakhari ED. Patient Dumping and the Emergency Medical Treatment and Labor Act (EMTALA). The National Law Review. October 11, 2016. Accessed July 3, 2018. https://www.natlawreview.com/article/patient-dumping-and-emergency-medical-treatment-and-labor-act-emtala.
  6. Henry J. Kaiser Family Foundation. Key facts about the Uninsured Population. November 2017. Accessed July 6, 2018. http://files.kff.org/attachment/Fact-Sheet-Key-Facts-about-the-Uninsured-Population.
  7. Kelly-Blake K, Garrison NA, Fletcher FE, Ajegba B, Smith N, Brafford M, Bogdan-Lovis E. Rationales for expanding minority physician representation in the workforce: a scoping review. Medical Education. Available online June 22, 2018. https://doi-org.proxy2.cl.msu.edu/10.1111/medu.13618.
  8. McDaniels AK. What is patient dumping? Incident with woman at Baltimore hospital is hardly new. January 11, 2018. Accessed July 3, 2018. http://www.baltimoresun.com/health/bs-hs-what-is-patient-dumping-20180111-story.html.
  9. Mitchell J. With 175 Americans dying a day, what are the solutions to the opioid epidemic? USA Today. January 29, 2018. Accessed July 6, 2018. https://usat.ly/2DU5isN.
  10. National Alliance on Mental Illness. Mental Health Facts in America. Accessed July 6, 2018. https://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf.
  11. U.S. Commission on Civil Rights. Patient Dumping Statutory Enforcement Report. September 2014. Accessed July 18, 2018. http://www.eusccr.com/patient_dumping.html.

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