In its sixth in a series of reports on patient dumping, Public Citizen found that 527 hospitals violated the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). That law contains rules that virtually all hospitals in the United States must follow regarding the provision of emergency medical services. When a hospital emergency department denies medical screening or stabilizing treatment, or if it inappropriately transfers an individual whose condition is not stable, the hospital is "dumping" the patient. Taking data from all six reports into account, more than one in five hospitals throughout the country have violated the law since it was passed. The report concludes that most hospital staff are familiar with the law but break it anyway.

"It’s distressing that this law has been in place for 15 years, and hospitals are still flaunting it," said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. "The government needs to do more to force hospitals to comply. People shouldn’t be denied desperately needed emergency medical care when they go to a hospital. Failing to impose fines on most hospitals violating the law amounts to an invitation to dump sick patients."

Most of the violations cited in the current report were confirmed in 1997, 1998 and 1999, although a few were confirmed in 1996 and 2000. Not all the hospitals violating the act actually dumped patients; some violations were administrative in nature, involving such things as omitting documentation or failing to post signs spelling out patients’ rights. The report lists the name of each hospital, the nature of the violation and any fines assessed against the hospital. Of the 500 hospitals that had confirmed violations in 1997, 1998 and 1999 and were eligible to be fined, only 85 (17 percent) had been fined as of April 2001.

According to records reviewed by Public Citizen, hospitals in 46 states as well as the District of Columbia and Puerto Rico were cited for violations. States with no confirmed violations were Delaware, Hawaii, New Mexico and Wyoming. Consumers wishing to find out which hospitals in their state violated the law can visit www.citizen.org after 1 p.m. EDT, go to "Questionable Hospitals," click on a map of the United States and select their state. A copy of the report is also posted there.

Among the report’s key findings:

For-profit hospitals had a significantly higher rate of violation (1.7 times higher) than not-for-profit hospitals.

Up to a third of surveyed emergency room registration staff recently told the U.S. Department of Health and Human Services Office of Inspector General that patients might be asked for insurance information before a screening is provided or while it is taking place, and 35 percent said they contact health plans for authorization of screening exams at some point. These actions violate the law if they delay treatment.

Hospitals are being fined more than in previous years. Civil money penalties increased from $130,000 in fiscal 1988 to more than $1 million in each of 1998, 1999 and 2000. However, the amounts paid are still paltry compared to a hospital’s overall budget and do nothing to discourage hospitals from turning needy patients into the streets. Worse, most hospitals with confirmed violations are not fined.

"The sad truth is that it’s cheaper for a hospital to break the law and pay a fine than to treat an uninsured patient," Wolfe said. "Hospitals know that the risk of getting caught is low, and even if they are caught, the risk of being fined is even lower and the fines are minuscule compared to hospitals’ operating budgets."

Some of the more egregious examples of patient dumping include:

A mentally retarded patient was brought by ambulance to Mercy Hospital in Merced, Calif., with symptoms of abdominal distress and shortness of breath. An on-call surgeon repeatedly refused to come to the hospital to treat the patient, who subsequently suffered a cardiac arrhythmia and died despite a resuscitation attempt. Documentation revealed that the surgeon made disparaging remarks about the man’s mental retardation, including the statement that "no one would miss him if he died." The man had lived in a board-and-care home for 15 years. As of April 2001, the hospital had not been fined.

A woman who went to Baptist Hospital in Miami, Fla., was found to have a large mass in her lower abdomen and an elevated white blood cell count, indicating she might have an infection. She was admitted for surgery, but before it occurred, the surgeon asked her for a deposit. The woman said she didn’t have the money, so the surgeon ordered the patient to be discharged. She left without receiving treatment. As of April 2001, the hospital had not been fined.

A patient went to the emergency room of Houston Medical Center in Warner Robbins, Ga., vomiting blood and complaining of a loss of appetite and a swollen and painful stomach. The patient’s symptoms indicated blood loss. He was treated with an IV solution, given prescriptions and discharged. An ambulance returned him to the ER about five hours later, at which point he was in full cardiac arrest and died six minutes later. As of April 2001, the hospital had not been fined.

Friends of a 15-year-old boy who had been shot in the abdomen dragged him into an alley next to Ravenswood Medical Center in Chicago and asked the hospital emergency room staff for help. The staff refused to go out to treat him or bring him into the hospital. After staff refused requests of police officers who repeatedly asked ER staff to come out and help, a police officer wheeled the boy into the ER in a wheelchair. Despite resuscitation efforts, the boy died. The hospital was fined $40,000.

While the records reviewed by Public Citizen generally don’t reflect the reason a patient was dumped, often it is because the patient was uninsured, Wolfe said. The law prohibits emergency room personnel from delaying screening or treatment to ask whether a patient has insurance, but personnel still do. Further, some HMOs require pre-authorization for exams or treatment, and some HMOs refuse to pay for emergency room treatment later if the patient is found not to have a condition that constitutes an emergency. This often means the hospital gets stuck with the bill, providing hospitals with a deadly incentive to dump uninsured or poor patients.

Federal legislation or new federal regulations could help, Wolfe said. The EMTALA could be amended to create liability for insurers that require pre-authorization or that refuse to reimburse hospitals for emergency screening and treatment.

California Supplemental Report

Texas Supplemental Report

Some of the Worst Confirmed Patient Dumping Cases

Where to Report violations of the EMTALA

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