In the waiting area of the ED at John H. Stroger Jr. Hospital of Cook County, rows of seats are filling up. It's shortly before noon in Chicago, but already more than two dozen people have found a spot in this room that looks more like an impeccably clean bus station than a medical center lobby.
One woman has been waiting with her daughter since early in the day, but that doesn't trouble her. The last time she was here, it took seven hours. “They are full up back there. I know it. I been here before, and they always are,” she said.
This tolerant mom confesses that she wishes the snacks in the vending machines cost a bit less — her little girl is hungry — but she understands. “They got to make their money some way,” she said.
Moneymaking, or rather the lack of it, underpins the very controversy that ends here, at the hospital many still call by its previous name: Cook County. Why are more people than ever, from all across the city, ending up at this particular destination?
Just ask David Levine, MD, the medical director of Stroger's emergency department, who has a growing stack of notes and papers from patients at other hospitals advising them to go to his ED. “I collect them,” he said matter-of-factly. The patients, largely uncomplaining, “come from all over, and they trust the care here.”
But this isn't the way it is supposed to happen, not even in a facility known for service to indigent patients. EMTALA is designed, in part, to prevent patient-dumping, a phenomenon Arthur Kellermann, MD, MPH, first documented 20 years ago in Tennessee when he and a colleague found that almost all of the transferred patients from one medical center in Memphis to another were for economic reasons. (Am J Public Health 1988;78:1287.)
After Dr. Kellermann, now the chairman of emergency medicine at Emory University in Atlanta, and several others published such findings, reforms followed, and the Emergency Medical Treatment and Active Labor Act (EMTALA), enacted in 1986, received interim final regulations in 1994.
Nevertheless, 15 years later, the same situation these regulations sought to prevent is still happening, and was chronicled by two reporters from the Chicago Tribune (April 10, 2009; http://bitly.com/Tribune). And they aren't the only ones. Similar stories have made news other places, where patients have been dropped off on city streets courtesy of taxi vouchers or whose relatives are given directions by hospital staff boldly waving them off to another ED. These “interhospital transfers,” as they are sometimes called, have been documented in every region of the country, but particularly in Texas, Florida, and the western United States. In one region, for example, emergency physician Charlotte Yeh, MD, reported that the the number of complaints increased from 658 to 744 over a two-year period ending in 2006, and the percent with violations rose from 30 percent to 40 percent. (EMTALA Anti-Dumping Update, Centers for Medicare and Medicaid Services, March 5, 2008. To read report, see EMN Online box.)
The development is causing some federal officials to ask whether hospitals should be allowed to keep their nonprofit status if investigators determine they have dumped patients. Currently, the U.S. Office of Inspector General (OIG) is drawing up plans to review CMS oversight of hospital compliance with EMTALA, including how CMS tracks and handles complaints. “The report is not likely to come out this year because of lack of resources,” explained Donald White, a spokesman for OIG. But the problem has hit the federal radar. A recent proposal from the U.S. Senate Finance Committee, for example, mandates that hospitals must demonstrate charity care to preserve their nonprofit classification.
“With the new Senate finance proposal, tax-exempt status may be in jeopardy, or there may be additional excise taxes levied on hospitals that do not provide adequate charity care,” said Jesse Pines, MD, an assistant professor of emergency medicine at the University of Pennsylvania School of Medicine and the Hospital of the University of Pennsylvania. “If hospitals are allowed to get away with it, and there is no downside, I see this as very likely to spread,” said Dr. Pines, who has investigated emergency crowding in a series of studies. (Acad Emerg Med 2008;15 :825.)
Probably nowhere has this alleged patient-dumping received as much attention as in the Windy City, partly because the University of Chicago made headlines recently for a plan to cut emergency beds, among other curtailments. It was singled out again in the Tribune series on ED care, this time about alleged transfers to Stroger.
Patients even arrive at Stroger bearing Google maps given to them by nonprofit hospitals, according to the Tribune article. “‘Go to Cook County Hospital immediately,’ says a discharge slip for a man with a broken jaw,” the article noted.
“Nonprofit hospitals, meanwhile, reap millions of dollars in property and sales tax breaks from the county based largely on the promise that they'll help the uninsured,” the Tribune reporters wrote. “Yet nonprofit hospitals in Cook County dedicated just two percent of their total revenue to charity care in 2007 — one percentage point more than for-profit hospitals that don't receive tax breaks, according to an analysis of the most recent state hospital revenue data.”
The article said administrators at nonprofit hospitals “vigorously deny” that they are dumping patients on Stroger, but defended triaging out some patients as “reasonable measures to ensure proper care without overburdening ERs.”
“This is basically legalized patient-dumping,” Dr. Pines told the Tribune.
“Despite its critics, the university provides far more unreimbursed care as a percentage of revenue than any of the largest hospitals in Chicago or most academic medical centers in the United States,” countered John Easton, a spokesman for the University of Chicago hospitals. According to data from the university, it provides significantly more Medicaid patient days than any other hospital system, with the exception of a health network that includes eight facilities.
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Read the Chicago Tribune article that exposed the allegations and a report from CMS about antidumping on EM-News.com. Go to EMN Online for August, and click on EMN FastLinks.