Patient dumping

Homeless veteran receives medical treatment.

Homeless dumping or patient dumping is the practice of hospitals or emergency services inappropriately releasing homeless or indigent patients indigent to public hospitals or releasing them on the streets instead of placing them with a homeless shelter or retaining them, especially when they may require expensive medical care with minimal government reimbursement from Medicaid or Medicare. The term homeless dumping has been around since the late 19th century and has resurfaced throughout the 20th century alongside legislation and policy changes aimed at addressing the issue. Many homeless people who have mental health problems can no longer find a place in a psychiatric hospital since the trend towards mental health deinstitutionalization from the 1960s onwards.

History

Early history

The term "patient dumping" was first mentioned in the New York Times in articles published in the late 1870s describing the practice of private New York hospitals transporting poor and sickly patients by horse drawn ambulance to Bellevue Hospital, the city's preeminent public facility. The jarring ride and lack of stabilized care typically resulted in death of the patient and outrage of the public. Scholars report that private hospital administrations were motivated by a desire to keep low mortality rates and costs poor critically to advise ambulance drivers to send ill patients directly to the public hospitals like Bellevue even if they were the closest hospital. After the deaths associated with patient dumping or inappropriate patient transfer added up, the first attempt at legislative reform in the United States was pushed through the New York Senate around 1907 largely by Julius Harburger. The legislation penalized private hospitals when they sent ill patients away or obligated staff to transfer them to another hospital. Notwithstanding the passage of city ordinances prohibiting the practice it continued. The practice of patient dumping continued for several decades and in the 1960's it was brought back into the public eye by the media, but not much was done to resolve the issue.

1980's resurface and policy interventions

"Patient dumping" resurfaced in the 1980s, nationwide, with private hospitals refusing to examine or treat the poor and uninsured in the emergency departments (ED) and transferring them to public hospitals for further care and treatment. In 1987 33 complaints of patient dumping were made to the US Department of Health and Human Services, and the following year 1988, 185 complaints were made. Since private hospitals ceased publishing their mortality rates, analysts pointed to high costs of dealing with Medicaid's reimbursements and uninsured patients as the motivation. This refusal of care resulted in patient deaths and public outcry culminating with the passage of a federal anti-patient dumping law in 1986 known as the Emergency Medical Treatment and Active Labor Act. In 1985 the Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed which was meant to regulate how patients were transferred and also end patient dumping. Unfortunately, COBRA was not a complete solution, and in the years after its passage hospitals struggled with creating appropriate discharge protocols and the cost of providing health care for homeless patients.

Early 21st century policy

Homeless dumping continued to be an issue in the United States into the 21st century. University of California Los Angeles professor, Abel (2011) claimed that these policy interventions have not been effective because the United States' health care system is too heavily influenced by the patients ability to pay. In the early 21st century, immigrant groups were vulnerable to patient dumping by being deported or repatriated which in many cases leads to their death.

Factors Associated with Homeless Dumping and Patient Dumping

Patients living in poverty or in homelessness are often seen as less than ideal patients for hospital administrations because they are likely to be unable to pay for their healthcare and tend to be hospitalized with severe illness. Other factors associated with patient dumping are being a part of minority group and being uninsured. As well as historically, the competitiveness between hospitals to maintain low mortality rates.

Some researcher and scholars trace the issue of homeless dumping to the issue of homelessness and claim that addressing the issues of homelessness will prevent patient dumping. Social factors have allowed homelessness and poverty rates to further increase, and deinstitutionalization has led to psychiatric patients to lose access to services and be dumped on the streets.

Intervention Strategies

The introduction of Medicade and Medicare had helped hospitals shoulder the burden of providing care to poverty-level and elderly patients, but the many of people in United States without health insurance were still vulnerable to inappropriate patient transfer or dumping.

Statistically, Texas and Illinois had the highest rates of patient dumping because of economic reasons. Texas state law had a loop hole that allowed hospitals to transfer patients to nursing homes. In 1985 Illinois developed the Illinois Competitive Access and Reimbursement Equity (ICARE) program but that program had adverse effects like disrupting indigent patient's continuity of care, losing patients, and creating 2 hospital systems: one for uninsured lower-income patients and one for insured higher-income patients. The ICARE policy had a negative impacted on the quality of healthcare that low-income and homeless patients received because it created disjointed treatments experiences when hospitals met their allocated funding quota and transferred patients to (or dumped patients on) other hospitals that still had funding and public hospitals. Proponents of the ICARE policy cited the reduction in Illinois' Medicare expenditure as evidence of the policy's success.

The 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) was meant to regulate Medicare-participating hospitals and ensure that patients received appropriate medical treatment regardless of their ability to pay.

In 1988 the COBRA Act was meant to be a series of revised regulations and required hospital emergency rooms to treat every patient that walked through to examine all patients seeking treatment and double the fine. News Editor for the American Journal of Nursing, Brider (1987) reported that public hospital staff in Illinois were under a lot of pressure due to the influx of patients that were being sent to them from other hospitals, and that the incidence of patient transfers or patient dumping increased through a loop whole in COBRA.

Some researchers and scholars have concluded that despite the policy interventions of the 1980's, the practice of patient dumping continued to be a problem in the United States and that a solution required a reformation of the entire healthcare system. These research shared opinion that the most effective solution to address the health care needs of people living in poverty and those who are homeless is to provide universal healthcare because that would eliminate hospitals incentives to turn patients away based on their ability to pay for services.  

Usage

• Associated Press; February 9, 2007; Los Angeles. A hospital van dropped off a homeless paraplegic man on Skid Row and left him crawling in the street with nothing more than a soiled gown and a broken colostomy bag, police said.... Police said the incident was a case of "homeless dumping" and were questioning officials from the hospital.
• Associated Press, October 25, 2006; Los Angeles. "L.A. Police Allege Homeless Dumping." Authorities have launched a criminal investigation into suspected dumping of homeless people on Skid Row after police witnessed ambulances leaving five people on a street there during the weekend.

See also

• Emergency Medical Treatment and Active Labor Act
• Skid row