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Are hospitals passing off their low-profit patients?
Stroger pays for transfers from non-profit hospitals getting tax breaks

Friday, April 10, 2009
Chicago Tribune
by Jason Grotto and Bruce Japsen

Indigent and under-insured patients are turning to Cook County's Stroger Hospital after not getting fully treated at non-profit hospitals, swamping the cash-strapped public facility while fueling the county's sky-high sales tax, a Tribune investigation found.

Some of these patients arrive at Stroger's emergency room bearing discharge slips, prescriptions, even Yahoo and Google maps from non-profit hospitals, according to documents obtained by the Tribune.

"Go to Cook County Hospitals immediately," says a discharge slip for a man with a broken jaw.

"Go to Cook County ER to be evaluated for admission," reads a discharge slip for a man with a tumor.

"Follow up at Cook County Hospital for uterine tumor surgery," says another discharge slip brought into Stroger, which still is referred to by many as the county hospital.

Non-profit hospitals, meanwhile, reap millions of dollars in property and sales tax breaks from the county, based largely on the promise that they'll help the uninsured.

Yet non-profit hospitals in Cook County dedicated just 2 percent of their total revenue to charity care in 2007—1 percentage point more than for-profit hospitals that don't receive tax breaks, according to an analysis of the most recent state hospital revenue data.

Even facilities outside Cook County, hospitals and clinics as far away as Lake and DuPage Counties, direct patients to Stroger, records and interviews show.

"We have so many of these patients that it creates a backlog and patients end up competing for limited resources," said Dr. David Levine, Stroger's medical director for Adult Emergency Services.

Handing out directions or referring patients to another facility isn't illegal. In fact, hospitals have no obligation to treat poor or uninsured patients outside of a federal law that requires them to examine and, if there's a medical emergency, stabilize those who show up in the ER, regardless of their ability to pay.

Some advocates and physicians argue that non-profit hospitals should be required to do more for needy patients, and that local taxpayers are carrying a heavy burden because of a lack of charity care. Taxpayers provide nearly half of the county hospital's revenues along with hundreds of millions of dollars in property and sales tax breaks to non-profits, according to recent estimates.

Unlike a private hospital, Stroger's mission is to act as a safety net for the poor and uninsured. But the hospital is bursting at the seams with patients while its financial struggles have led to deep staff and service cuts.

Those troubles also contributed to an increase in the county's portion of the sales tax, which is now the highest in the country.

Officials at non-profit hospitals contacted by the Tribune vigorously deny that they steer patients to Stroger's ER and say that they treat everyone who shows up at their hospitals.

They defend policies that move some patients out of emergency rooms—known as "triage out"—as reasonable measures to ensure proper care without overburdening ERs.

"Is it unreasonable for hospitals to ask if there are better ways to care for people more efficiently?" asks Howard Peters, senior vice president of governmental affairs for the Illinois Hospital Association.

But some ER doctors are concerned about these policies and what they mean for quality of care for poor patients.

"This is basically legalized patient dumping," said Dr. Jesse Pines, an assistant professor of emergency medicine at the University of Pennsylvania School of Medicine.

Pines also is a member of the American College of Emergency Room Physicians, which recently criticized the University of Chicago Medical Center for plans to send non-urgent patients to other facilities while cutting the number of inpatient beds available to the ER.

The group's members argue that because ERs are staffed and equipped 24 hours a day—regardless of who shows up—the added costs of caring for patients with non-urgent ailments is comparable to a doctor's office visit.

"We have a responsibility to rule out an emergency medical condition," said Dr. Catherine Marco, an ER professor at the University of Toledo and a member of the American College of Emergency Room Physicians' ethics committee. "If we're going that far, why not close the loop? At that point, it's not a labor intensive issue."

Critics of the U. of C. plan questioned whether it was a way for the hospital to avoid caring for indigent and Medicaid patients. Parts of the plan were later put on hold after two national ER physician groups and doctors inside the medical center spoke out against it.

Resurrection Health Care, with eight hospitals in Chicago and Cook County suburbs, runs a program similar to the one outlined by U. of C., only Resurrection's policy has been in place for more than a year.

Like the U. of C. plan, Resurrection's Health Access Service says nothing about insurance status, describing the program as a way of finding primary doctors for those seeking non-urgent care in the ER.

"It came about because of patient need," said Joan Ormsby, vice president of Resurrection's West Suburban Medical Center in Oak Park. "It's about getting people to the appropriate level of care so they don't have to use the [Emergency Department] as their last resort."

Resurrection officials say that the policy gives patients the choice of whether they want to be treated at a Resurrection hospital or be referred to a clinic. They also say their hospitals have never denied treatment to any patient because of insurance status, and never refer patients to Stroger.

Shown three discharge slips that explicitly direct Resurrection patients to Stroger, officials said there were special circumstances in each of those cases, including not having specialists available to treat the patient in one case.

Resurrection officials say only 1,100 patients have been referred outside of the hospital since the policy was put in place in November 2007. Of those patients, more than 70 percent were either uninsured or on Medicaid.

At Stroger, doctors and nurses are especially concerned about patients who have been stabilized after an emergency at another hospital but then must search out urgent follow-up care.

Uninsured cancer patients, Medicaid patients with heart disease and immigrants with broken bones often show up in Stroger's ER after being stabilized or evaluated elsewhere, according to interviews, documents and lawsuits.

Lake County Health Department documents obtained by the Tribune describe a man with AIDS coughing up blood who ended up in Stroger's ER for treatment instead of the numerous hospitals that receive subsidies from Lake County taxpayers.

"Our policy is we do not refer patients to John Stroger Hospital because we know they can't absorb the patients," said Leslie Piotrowski, a spokeswoman for the department, which operates clinics in the county. "If we give them a referral, they can go wherever they like. But we don't specifically tell them to go Stroger."

At Stroger, it's not unusual to find gurneys clogging the hallways of the emergency room while nurses shuffle beds to make room for new patients.

"We not only handle a huge emergency load but we're filling other holes in the safety net," said Dr. Steve Aks, a 7-year veteran of Stroger's ER. "That's the reality."

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