Patient dumping: What not to do when patients can’t pay

It was a sickening scene that could leave any clinician seething with outrage. A news camera rolled as security officers at Valley Hospital Medical Center in Las Vegas ushered an elderly woman, struggling with her walker, across a city street. Then the officers left her lying on the sidewalk outside of University Medical Center (UMC).

Las Vegas elected officials have labeled the November 2022 incident as patient dumping, defined in an article published by AIMS Public Health as denying patients treatment due to their inability to pay for it.^[]

It’s an illegal practice that persists in the US, despite efforts to curtail it. Fortunately, there are legislative barriers in place to stop patient dumping, as well as steps clinicians can take to address it.

Inside the Las Vegas incident

In an interview with a local news affiliate, UMC Board of Trustees chairman William McCurdy II said that patient dumping had long been rumored in the community. He also reported that, as of the day of the incident in November 2022, the patient was receiving care at UMC.

McCurdy said he would report the alleged violation to the Nevada State Department of Health and Human Services and the Joint Commission.

Other instances

Patient dumping isn’t confined to a single Nevada county, unfortunately. In October 2022, two Kentucky hospitals lost $2.4 million each following patient-dumping lawsuits.^[]

One suit began when a behavioral therapist reported that supervisors told her to persuade psychotic, suicidal, or homicidal patients that they no longer had these problems and could be discharged. In truth, these patients either could not pay for care or had reached the limits of their insurance coverage.

The second suit involved a man who was diverted from one hospital to another while being transported by EMS after suffering a heart attack. The first hospital allegedly diverted the man because, unbeknownst to the ambulance service, it did not have a cardiothoracic surgeon on call.

There have also been a few other high-profile incidents in recent years:

• In 2015, Nevada paid San Francisco $400,00 to settle allegations that the state wrongfully bused psychiatric patients to the California city, despite the fact that many of them had no connections there.

• In 2016, a Los Angeles hospital settled a case for $450,000 after a homeless patient with a foot infection was prematurely discharged and given a bus token.

• In 2020, a Georgia hospital settled a case for $260,000 after it failed to provide adequate screening, examination, and stabilizing treatment for 21 individuals.

Arguably, none of these instances should have happened, owing to one specific piece of legislation: EMTALA.

Inside EMTALA

The Emergency Medical Treatment & Labor Act (EMTALA) became law in 1986.^[]

It ensures patients’ access to emergency care, regardless of their ability to pay. Additionally, the Social Security Act mandates that any hospital participating in Medicare and offering emergency services must provide a medical screening examination whenever there is a request for an examination or treatment for an emergency condition. This includes patients who present in active labor.

Hospitals are legally bound to stabilize any patient presenting with an emergency medical condition. If they can’t do this, or if the patient requests a transfer, they must transfer the patient to another facility.

ACA impact on EMTALA lawsuits

The study published in AIMS Public Health tracked EMTALA lawsuit trends between 2002 and 2015, spanning the period after the Affordable Care Act (ACA) became law in 2010 and lowered the rate of uninsured individuals.

Researchers found that the number of violations declined during the study period. The high was 46 in 2002 and the low was 6 in 2015, marking an 87% drop. The researchers also identified some commonalities:

• Settlements mostly stemmed from failure to screen or stabilize patients seeking emergency care.

• Settlements were most common in the US South and in urban areas.

• The average settlement was $31,734.

• The total awarded during the study period was $5,299,500.

“Furthermore, while a causal relationship cannot be determined from the present analysis, it is possible that the ACA helped to reduce patient dumping,” the researchers added.

How clinicians can help

Clinicians can take steps to help prevent patient dumping. That effort begins with familiarizing themselves with section 482.43 - Condition of participation: Discharge planning from the Code of Federal Regulations.^[] These rules codify certain requirements for the hospital discharge process. Those requirements include:

• Identifying patients who may experience health difficulties after discharge without sufficient discharge planning

• Planning discharge for these patients, and others who request discharge planning

• Documenting discharge planning

• Discussing plans with the patient or their representative

• Administration of discharge planning by an RN, social worker, or other “qualified personnel”

• Assisting patients, families, or their representatives in choosing post-acute care clinicians

Writing for Nurse.com, Jennifer Mensik, PhD, RN, also provided some guidance that clinicians can use to navigate the legal requirements for discharge:^[]

• Critiquing discharge plans if these plans feel “off”

• Requesting social worker consults for patients

• Documenting the clinician’s guidance on discharge planning for each patient

• Requesting patient-care conferences to solidify discharge plans

• Knowing what charity care options the hospital offers

• Keeping a supply of donated clothes for patients if they need them