HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Saturday, August 2, 2008

L.A. Law May Keep Homeless in Hospitals

The Wall Street Journal reports on a Los Angeles city ordinance that will cut down on the number of hospitals dropping homeless patients onto skid row by making it a misdemeanor for health facilities to transport patients to places other than their residences without written consent.  Rhonda L. Rundle writes,

AmbulanceHospitals here have been shamed in recent years by reports some of them dumped homeless patients onto downtown's skid row before they were well enough to care for themselves. Now, hospitals caught in the act will be charged with a crime.

A new city ordinance, believed to be the first of its kind in the nation, makes it a misdemeanor for health facilities to transport a patient to a place other than his or her residence without written consent.

Hospital administrators fear that a conviction could trigger an automatic exclusion from government health programs, a financial blow few hospitals could survive. They also worry about the cost of keeping patients who are healthy enough to be discharged but have no place to go.

Homeless patients have at times received poor treatment by hospitals in other U.S. cities, but the issue has been particularly visible in Los Angeles because of documented reports of patients being dropped off at shelters. The issue achieved national attention after last year's Michael Moore film "Sicko" included video of an elderly woman apparently being dropped off by a taxi on the street while wearing little more than a hospital gown.

"The most important thing is to get culture change in the way that hospitals discharge patients," says a spokesman for Los Angeles City Attorney Rockard J. Delgadillo, whose office is investigating about 50 suspected dumping cases from before June 30, when the law took effect.

The Hospital Association of Southern California says it has asked an attorney to investigate whether the measure violates state law. The association is also seeking clarity from the federal agency that oversees Medicare on the consequences of a conviction.

Several hospitals have admitted failings in their procedures for homeless patients and say they have made changes. They say it has become increasingly difficult to discharge these patients because many refuse to leave.

While the hospitals say they accept their responsibility for the patients' medical care, they say they are being asked to house them after they are treated. The average length of stay for a homeless patient is 4 1/2 days longer than that for others with comparable conditions, says James Lott, executive vice president of the hospital association.

Los Angeles doesn't have enough "recuperative beds," a type of transitional housing for discharged hospital patients who need further medical attention. To help alleviate the shortage, county agencies and private hospitals are financing a pilot project to add 30 beds, bringing the total to 75. Hospitals are also revising procedures for discharge planning, including specialized training for staff members.

A financial crisis in the county's public-health-care system in recent years has led to the closure of many community clinics where homeless people used to go for primary care, so now they are more often going to hospital emergency rooms, Mr. Lott says.

In hospitals, patients have a "nice, warm bed, three meals a day and maybe even a television and people waiting on them. They are literally saying to us, 'I don't want to go. If you discharge me, I will call the L.A. Times,'" says Carol Meyer, director of governmental relations for the Los Angeles County's Department of Health Services.

Thirty to 50 homeless people who no longer have a medical need to be there stay at the county's downtown hospital every night, she says.

Some hospital officials and employees say the new law is being used as an excuse by shelters to deny priority to homeless people after they are well enough to leave the hospital. "When you call a shelter and say, 'We have a patient with no acute-care needs that we would like to send,' all they say is, 'Have them go stand in line at 3 p.m.,'" Ms. Meyer says. Hospitals have little choice but to spend more than an average $1,350 for a homeless person to spend the night, Mr. Lott says.

Last year, one homeless man in his 40s spent several months at Methodist Hospital in Arcadia, Calif., a Los Angeles suburb, after his medical condition had stabilized, says Gloria Nuesch, director of the hospital's care-coordination department. He didn't want to leave, so the hospital kept him until it was able to enroll him in a government-assistance program. Complying with the city's new law is difficult, she says, because about half the hospital's homeless patients won't sign discharge consent forms. "We can't force them," she says.

Methodist Hospital, Hollywood Presbyterian Medical Center and Kaiser Permanente, a managed-care organization, have each reached agreements with Mr. Delgadillo's office over the past year or so to resolve investigations into alleged incidences of patient dumping.

The Rev. Andy Bales, director of Union Rescue Mission, the city's largest homeless shelter, says he is "thrilled" that the new law is working well. The mission can't always accept discharged patients, he adds, because "we can't medically meet their needs." He says he doesn't discuss the new law with homeless guests, but he acknowledges that "these can be difficult patients to deal with."

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