Quora Query: Have You Ever Witnessed Hospital Administration Turn Away a Patient that Should have Been Seen Right Away?

In the United States, complements of a law passed in 1986 – The Emergency Medical Treatment and Labor Act (EMTALA) – a hospital cannot turn away someone who has an emergency. Rather, the institution must treat it – at least to stabilize the patient – before transferring the person or discharging them.

This act came about – among other reasons – after an article was published in the New England Journal of Medicine by a group of my (at the time) colleagues from Cook County Hospital (Transfers to a Public Hospital. Robert L. Schiff, M.D., David A. Ansell, M.D., James E. Schlosser, M.D., Ahamed H. Idris, M.D., Ann Morrison, M.D., Steven Whitman, Ph.D. N Engl J Med 1986; 314:552-557).

The institution directly across the street from us – Rush Presbyterian St. Lukes Medical Center – would simply send the poor directly from their Emergency Department (ED) to us at CCH, stable or not. This was related to the patient’s ability – or inability – to pay. And this was an administrative decision, which the physicians and nurses were obliged to follow.

The EMTALA of 1986 demanded that, whatever the financial status of the person who presents to the ED, if they have an emergency condition – one in which life or limb is threatened or potentially threatened – they must be stabilized before being discharged from the institution.

If the person has a condition that is deemed not to be an emergency, and they do not have the ability to pay for the care, the person can be turned away from the ED.

This – what I consider inhumanity – is one of the reasons we in the US must have some form of a national health service. While some of our peer nations – such as the Netherlands – achieve this with very tightly regulated insurance companies, other do it with a Medicare for All function – Canada for example; and others have a mix.

I support – and have argued for since the mid-1970s – the Sanders’ / Warren Medical for All plan. In a country as wealthy as ours, it is criminal that we have people who are unable to appropriately obtain medical care and medications.

Finally, as one who has worked in EDs for a good while, it must be stated that the ED is not the best place to obtain primary care. A rational system would have easily accessible primary care to deal with most routine issues, with ED visits saved, generally, for emergencies.

One last point, somewhat related to this. There has been some bru-ha-ha in the Twitter-sphere of late related to “Surprise bills” after surgical procedures. A recent Atlantic article suggests that we physicians bring in people – purposefully? – who are out of network so that we can (??) drop extra bills after the procedure. This is patent bullshit.

I don’t like the idea of surprise bills any more than anyone does. But these exist because of our for-profit and outmoded health system finance scheme. As a practicing physician, I have NO IDEA, in the ICU or in the Operating Room, what is or isn’t covered; what is or isn’t in or out of network. We take care of sick people. It is the administration who is supposed to figure out the workings of the insurance companies. Not us, and certainly not while we are caring for you.

Yet another of the 320 million reasons that we must have Medicare for All.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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