Patients who cannot pay for hospital care are being transferred from private hospitals to Cook County Hospital for economic rather than medical reasons, a study published in Thursday`s New England Journal of Medicine concludes.
The rate of such transfers has risen dramatically since 1980, when federal support for medical care to the indigent began to decline. In 1980, the number of transfers to County Hospital was 1,295, and three years later it had tripled.
The study provides scholarly support for what physicians in County Hospital`s department of medicine have contended for years: that private hospitals in the area are shirking their duty to provide care to the needy. In many cases, patients in unstable condition were brought to the public hospital from private hospitals, the study found.
The study was written by Dr. Robert L. Schiff and colleagues in County Hospital`s department of medicine and by Steven Whitman of Northwestern University`s Center for Urban Affairs and Policy Research.
Members of County Hospital`s surgery department who cooperated in the study declined to be listed as authors because their views were excluded from the study`s conclusions, said Dr. John Barrett, director of the trauma unit at County Hospital. The surgeons agreed with the study`s statistics on the transfers, but not with its conclusion that the transfers were always inappropriate.
The study focused on 467 patients transferred to County Hospital from 42 private hospitals between Nov. 20, 1983, and Jan. 1, 1984. Reasons for the transfers were available in only 52 percent of the cases, but among those cases, 87 percent were because of lack of insurance.
Among nonsurgical patients, a minority of those transferred, the death rate was nearly three times as high as for those patients admitted to the hospital directly. Although the cause of this isn`t known, the physicians speculate that ”some aspect of the transfer process, such as treatment delay, may have affected outcome adversely.”
Among surgical care patients, who constituted nearly three-fourths of those in the study, there was no difference in death rates.
The study found 81 percent of the transfer patients were unemployed and 89 percent were black or Hispanic.
According to the study`s authors, 24 percent of the transfer patients were unstable at the time of transfer. Twenty-two percent required admission to County Hospital`s intensive care unit, usually within 24 hours of admission.
Only 6 percent of the patients had provided written consent for the transfer.
”We conclude that patients are transferred to Cook County Hospital from other hospital emergency departments predominantly for economic reasons,” the authors wrote. ”The fact that many patients are in a medically unstable condition at the time of transfer raises serious questions about the private health sector`s ability to consider the condition and well-being of patients objectively, given the strong economic incentives to transfer the uninsured.” Barrett, the trauma unit director, said that even though he and other surgeons cooperated in the study, they could not agree with its conclusions. He said the study suggests it is inappropriate that poor people be transferred to County Hospital.
”County exists to take care of the indigent,” he said. ”The fact that other hospitals send them to us should come as no surprise.”
Even if patients are transferred in unstable condition, that doesn`t suggest the private hospital was wrong to make the transfer, especially in the case of trauma patients, Barrett said.
”If a man falls three stories from a building and blood is building pressure on his brain, he is dying and needs skilled surgery at once,”
Barrett said. ”Most community hospitals aren`t equipped to do this and should transfer the patient to us at once.
”The only fault here is that he was taken to the wrong hospital in the first place, not that he was transferred in an unstable condition.”
In an editorial accompanying the study, Dr. Arnold Relman, editor of the journal, said the study documents a nationwide trend of ”dumping” patients from private hospitals to public facilities. He praised Texas, which recently passed a state law intended to eliminate the practice.
