Private hospitals in Washington increasingly are refusing to admit poor people and instead are transferring them to the city's public hospital, D.C. General.
In recent years, patient transfers to D.C. General have risen 374 percent, according to the hospital's director, Robert B. Johnson. The hospitals transferring the most patients, he said, are the ones closest to the public facility -- the Washington Hospital Center, Capitol Hill Hospital and Greater Southeast Hospital, he said.
In the year that ended Sept, 30, 904 persons were transferred to D.C. General from Washington hospitals. Three years ago, that figure was 169 persons.
"We're afraid this is part of the phenomenon of patient dumping," said Dr. Jessie Barber, a neurosurgeon who practices at D.C. General and Howard University hospitals. "Patients who have no insurance are transferred to D.C. General because, by law, that hospital takes all patients."
Traditionally, hospitals have cared for anyone who presented themselves, writing off the losses as charity care. Area hospital officials say they continue to admit people needing emergency treatment, whether or not they can pay.
But with increased competition from suburban hospitals for paying patients, declining revenues because of fixed government payments and the growing number of people not eligible for welfare who are without health insurance, Washington hospitals are finding they cannot give unlimited free care to nonemergency patients.
"Our free care load has been rising, particularly in 1984," said Barry Passett, president of the Greater Southeast Hospital Foundation, who said the hospital is giving 11 percent of its care for free, up from its usual 8 percent.
The hospital cannot continue to treat everyone who asks for help, he said, because "a bankrupt institution out here is not going to help people east of the river." As a result, "We've become very careful in our pre-admission screening program," Passett said. " Some people who are not emergency cases, who are stable and are appropriate for transfer have been transferred to D.C. General."
The Washington Hospital Center transferred 20 of its emergency room patients to D.C. General Hospital in June, July and August. The patients were transferred for financial reasons or because they were under police custody, said hospital spokeswoman Stephanie McNeill. Another 39 patients were transferred to other hospitals during that period, she said, mostly on the orders of the patients' health maintenance organizations.
Under federal and city rules, most hospitals are required to give 3 percent of their care for free. Most far exceed that amount. According to the D.C. Hospital Association, Washington hospitals give about $70 million in free care each year, in addition to the $35 million in free care given by D.C. General. "In spite of the transfers, there is a fair amount of charity care given in the city," said Johnson.
The problem here and across the country is that the burden is not equal but falls most heavily on a handful of hospitals -- chiefly the public hospitals and those located in poor neighborhoods. "Locally and nationally, we must deal with the care of the indigent," said Johnson. "It's the single most important hospital issue today."
Passett is urging the D.C. Hospital Association to follow the lead of Florida, which requires all hospitals to pay 1 percent of revenues into a fund for charity care. An association committee, which met last week, is studying the plan. Another method, used in Maryland, is for a state commission to set hospital rates that "require the carriage trade hospitals to contribute to the care of the poor," he said.
At D.C. General, a private ambulance is dispatched for patients after a hospital calls to make a transfer. But at least one private hospital in Los Angeles handed out maps to poor patients showing them the bus routes to take to a public hospital, Andrulis said.
"As public hospitals we don't want to close the doors, but we're concerned about inappropriate transfers," said Andrulis, whose association is studying patients who are transferred when their insurance runs out and government-insured patients who are denied admission in private hospitals because of their ailments are expensive to treat.
To deal with such problems, D.C. General has established policies that insist that a doctor at the transferring hospital talk to a doctor at D.C. General about the incoming patient. The patients' medical records must accompany them. Johnson said that once a patient is admitted to another hospital, he or she cannot be transferred to D.C. General in the midst of treatment. He said since the policies were issued last November, there have not been major problems with hospitals transferring seriously ill patients.
The increased patient transfers raise the problem of encouraging a two-tiered system of medicine, where the poor receive care in public facilities and those who have insurance use private facilities. The federal health programs of Medicare and Medicaid have allowed poor Americans to use nearly all health facilities, but new limits on eligiblity for welfare, and therefore Medicaid, have dropped thousands of people from those programs in recent years.
John Ashby Jr., associate executive director of the D.C. Hospital Association, noted that this increase in low-income patients, plus more drug and alcohol problems and the attendant security costs, have added financial burdens to public hospitals.
But private hospitals have been unable to help because of declining revenues, he said. He noted that fixed payments for Medicare patients, which began to be phased in last year, "will result in big losses in our hospitals. They have to compete and we can't direct them to accept more no-pay patients."
"It's a national phenomenon," said Ashby. "Money is getting tighter. Before, the District government could count on other hospitals a little bit more to take care of their problem. For better or for worse, that's no longer true."