Homeless dumping or patient dumping is the
practice of hospitals and emergency services
inappropriately releasing homeless or indigent
patients to public hospitals or 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 used since
the late 19th century and has resurfaced throughout
the 20th century alongside legislation and
policy changes aimed at addressing the issue.
Different research studies have had mixed
results as to the effectiveness of the United
States' policy interventions and have propose
varying ideas to remedy the issue.
== History ==
=== Early history ===
The term "patient dumping" was first mentioned
in several New York Times articles published
in late 1870's, which described 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 mortality
rates and costs down when they advised ambulance
drivers to send poor patients in critical
condition directly to the public hospitals
like Bellevue even if a private hospital was
closer.
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 1960s it was
brought back into the public eye by the media,
but not much was done to resolve the issue.
Many homeless people who have mental health
problems can no longer find a place in a psychiatric
hospital because of the trend towards mental
health deinstitutionalization from the 1960s
onwards.
=== 1980's resurface in the public eye 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 (EMTALA).
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.
Statistically, Texas and Illinois had the
highest rates of patient dumping because of
economic difficulties.
Researchers have reported that the language
in COBRA was not precise enough to significantly
disincentivise healthcare providers to discontinue
patient dumping practices.
For example, in the 1980s Texas state law
had a loop hole that allowed hospitals to
transfer patients to nursing homes.
=== 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
led to their death.
Research articles also describe dumping of
homeless individuals or mentally ill individuals
by police as another form of inappropriately
shifting people from one area of a city to
another instead of taking them to adequate
care facilities like shelters.
In September of 2014, the U.S. Commission
on Civil Rights issued a report entitled "Patient
Dumping."
== Statistics ==
A report published in 2001 by the Public Citizen's
Health Research Group stated that there were
widespread violations of EMTALA throughout
the United States in 527 hospitals.
Between 2005 and 2014 another study reported
43% of the US hospitals studied had been under
EMTALA investigation which resulted citations
for 27% of the hospitals.
The other findings of this study were that
the number of EMTALA violations have been
decreasing for the period between 2005 and
2014, and that the majority of the citations
were given to hospitals for issues with policy
enforcement.
However, there is not a consensus among researchers
about how to effectively measure the effects
of EMTALA at reducing patient dumping or improving
patient care.
== Associated factors ==
Patients living in poverty or in homelessness
are often seen as less than ideal patients
for hospital administrations because they
are unlikely to be able 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.
Historically, hospitals have been reported
to compete against each other to maintain
low mortality rates at the expense of low-income
patients.
Competition within hospitals to see more patients
and faster also increases the rate of inappropriate
patient discharges.Some researchers 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.
The increase of homelessness and poverty rates
increases the number of people who are unable
to pay for consistent healthcare which leads
to emergency hospitalization of patients with
exacerbated medical conditions.
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 Medicaid and Medicare
had helped hospitals shoulder the burden of
providing care to poverty-level and elderly
patients, but the many people in United States
without health insurance were still vulnerable
to inappropriate patient transfer or dumping.
Scholars and researchers point to these patients'
lack of access to preventative and consistent
healthcare treatment as well as inappropriate
discharge procedures and follow-up protocols
as the causes behind the frequent rehospitalization.In
1985 Illinois developed the Illinois Competitive
Access and Reimbursement Equity (ICARE) program,
but it 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 impact on
the quality of healthcare that low-income
and homeless patients received because it
created disjointed treatment 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.
Some scholars described how EMTALA provided
a means to take legal action against healthcare
providers and hospitals that did not comply,
and provided examples of cases in Florida,
California, and North Carolina.
Even though hospitals have had to pay penalties,
patient dumping remained an issue throughout
the country.
Legal scholars, Kahntroff and Watson (2009)
also reported that the implementation of the
policy has been flawed with issues of lack
of adherence and confusion on what is compliance.
A study that looked at 5,594 hospitals in
the United States between 2005 and 2014 reported
that the number of EMTALA investigations has
decreased through that period which may be
an indication that hospitals and physicians
are improving their adherence to EMTALA protocols.
The decrease in EMTALA investigations might
also indicate that patient access to emergency
care and treatment is improving.
Researchers also interviewed doctors who reported
that EMTALA citation fines were a disincentive
to violate EMTALA protocols.In 1988 the COBRA
Act was meant to be a series of revised regulations
which required hospital emergency rooms to
treat every patient that walked through the
door and doubled the fine for violations.
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.The incentives offered to doctors in
terms of payment for their services have an
effect with patient care outcomes and can
minimize the chance of patient dumping or
shifting patients to other providers.
A study conducted on doctors at the Fairview
Health Services hospital in Minnesota reported
that grouping doctors into teams to incentivize
collaboration between the doctors to ensure
the average of the team provided high quality
health care for the patient.
But doctors who out performed other doctors
on their teams did not like the program because
the other doctors who were underperforming
did not have the incentive to improve.
Some of the doctors interviewed in the study
claimed that underperforming doctors would
only start providing better care if their
pay was affected by their lower quality services.
=== Discussion of intervention strategies
===
Some researchers and scholars have concluded
that despite the policy interventions of the
1980s, 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 researchers shared the 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.
Other researchers emphasize that better developed
protocols and procedures for patient discharge
are one of the most important strategies to
reduce rehospitalization rates because patients
living in homelessness and poverty lack appropriate
dwelling to continue the recuperation process.
Another strategy to minimize rehospitalization
rates proposed by researchers was to create
recuperation programs for patient who lack
access to one after they are discharge.
Respite programs can be especially helpful
for homeless patients to have safe places
to recuperate and stop the cycle of chronic
re-admittance.
A study conducted using information about
homeless patients in New Haven, Connecticut
reported that homeless patients had a 22%
higher hospital readmittance rate than patients
with insurance.Regional or community wide
programs to oversee under-resourced patient
recuperation or respite care seem to be the
most sustainable because they pool resources
from multiple hospitals and a larger population
to provide appropriate recuperation facilities
and minimize the risk of any one hospital
or healthcare facility from having to provide
the majority of the resources and cost associated
with the increase of patients from the area's
underserved patient population.
Researchers say that the cost of rehospitalizing
patients for more critical conditions is higher
than the cost of providing appropriate healthcare
and following careful patient discharge procedures,
which in some cases are beyond the requirements
outlined by policies like the EMTALA.However,
there are studies that have indicated that
hospitals sometimes face delays when discharging
a homeless patient because they also have
the responsibility of finding appropriate
housing and care.
Patients can also face adverse effects if
they are hospitalized for longer than what
is necessary because it increases their chance
of transmitting an infectious disease in the
hospital or it draws resources from other
patients.
== Global perspective ==
=== Canada ===
A study conducted on physicians in Ontario
investigated how different payment systems
impacted patient care in terms of the number
of cost shifts and dumping incidences and
reported that other factors like altruism
or ethics of the doctors and patient behavior
played a role in how doctors shifted costs.
Some researchers hold the view that the Canadian
healthcare system is better designed to minimize
the occurrences of patient dumping.
=== Taiwan ===
A study published in 2006 that used voluntary
surveys in its methods claimed that the results
of the surveys indicated patient dumping was
a problem within Taiwan's healthcare system.
Researchers report that funding issues with
government budgets and pressure that hospitals
felt to stay competitive were among of the
contributing factors to patient dumping.
A previous study published in 2003 also supported
the claim that Taiwan's healthcare system
is negatively impacted by patient dumping
in terms of healthcare quality and increased
costs.
=== United Kingdom ===
In the a study conducted in the United Kingdom
the issue of inappropriately discharging a
patient has more to do with delaying the discharge
than expediting the discharge.
In 2004 a report was published in the UK that
claimed that prisons were overcrowded and
that one of the populations at risk of living
in adverse conditions were mentally ill incarcerated
individuals who were dumped in prisons.
== Usage ==
=== Other associated names or terms ===
Other terms used in related to the practice
of patient dumping are frequent-user patient,
revolving-door, and bed block-blockers.
These terms were contrived by some hospital
staff who noted how these patients had reoccurring
hospitalizations.
Other ways homeless dumping is described is
with phrases like inappropriate patient discharges
and economically motivated transfers.
=== Usage in the media and press ===
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 ==
Greyhound therapy
Emergency Medical Treatment and Active Labor
Act
Skid row
== References ==
