[NPInfo] A reply to Nina

[Jeffrey Hazzard]

Nina,
   
     If the situation is as you say, I am sorry I doubted you, or believed you had the story wrong.  I am aghast.  Where is your practice?  This sounds like a backwards good-ole-boy situation.
   
     May I suggest several things.  First, you need to get another NP or PA partner on-the-job to ease the load.  Second, you need to document the testimony of the family or patients on their mistreatment, on video tape.  Third, you need to compile an irrefutable sum of cases against the offending hospital (if they accept Medicaid and Medicare, they MUST see patients in an emergency room visit and MUST admit those who meet objective admission criteria.  They may not like it, but that's the law.  I've been involved in explaining these facts to rural back woods Florida hospital administrators.  I've had to explain to several that they, in fact, are part of the USA and that the laws apply to redneck po-dunk, too).  Fourth, you need to educate your patients to advocate for themselves.  Ask them to get the reason for refusal of admission in writing, or better yet, on video tape.  The rest of what I've written below is a detailed plan of action.  You are doing very noble work in
 a bad situation and I admire your tenacity and your humanity in the midst of adversity.
   
    NOTES on how to win a battle of wits with unarmed administrators:
   
    Even a refusal by a hospital official (ER doc) to go on the record, on tape, is damning.  Even the patient asking for an explanation at the triage desk, on the way out of the hospital, of why they are being refused hospital admission and the refusal of the ER doc to provide that explanation, is damaging.  Even low quality digital cell phone video evidence is ugly to defend against.  Video tape is the gold standard and the great equalizer.  If you had been able to capture the lame "we don't want our staff to catch what he has" refusal for admission of your COPD patient on tape, and then a video of his respiratory status when the paramedics were treating him in your office after he stopped breathing, you'd have that hospital by the short hairs.  
   
     You can hold the higher moral ground when you get the evidence.  You don't have to put the video tape on CNN.  You can demand a viewing of it before the hospital board of directors and the administrator.  You can leave them the tape (copy of original, of course) with many instances of COBRA law violation (BUT NOT ALL OF YOUR GOODS ON THEM--keep the best in reserve for the predictable "this is an isolated incident" rebuttal).  You can leave that meeting with a statement, "I think we all know how this would appear to the viewing public."  It will make them weak in the bowels.
   
    But let me warn you.  This is going to make them very angry.  Taking control from them of their hospital and setting policy will make them be out to get you.  You have to decide if this hill is worth dying for.  You have to be ready to strike back with the power of the press if they act to malign your practice.  You have to be very deft at the statements you make to the press.  It isn't about you, and even one statement about you will discredit you.  You must keep the focus on patient access to care and on advocacy for the indigent/powerless.  You must be fair to the hospital when you speak to the press and say, "I fully understand why the hospital takes the action it does--we have no effective way in our country to deal with the uninsured patient who befalls a catastrophic illness.  We are all pawns in a national chess game.  But the law is very specific on these points.  Any hospital that accepts federal reimbursement by Medicare or Medicaid and runs an emergency
 department must provide care based on medical need.  We can all imagine what would happen if every hospital took the action that this one has."
   
      At the same time, you need to find the federal officials and the closest big city newspaper investigative reporter (MUST BE THE SAME STATE that the hospital is in) and tell them in summary what your patients are telling you.  Don't mention the hospital by name to the government or the newspaper.  When the federales and reporter ask which hospital it is, tell them, "In the interest of patient advocacy, I'd rather not say just yet."  Don't volunteer that you have any evidence unless asked, and then only tell them, "I might have some information that could be considered so."  They would ask for the information you have, and you should say that you plan to discuss the situation with hospital officials, but that you will give your evidence to them if the hospital isn't receptive to making changes "in the interest of patients."  The government only wants compliance, and if you get compliance by the threat of federal whistle-blowing, the government will be satisfied. 
 They'll likely tell you good luck and to come back if you don't get action.
   
      You must be very resolute and very brave to go up against the hospital.  But you don't need a dime.  When, and if, you get push back from the hospital, the first thing you need to do is ask to have a 1/2 hour meeting with the hospital's attorney.  Show the attorney the limited video evidence that you showed the hospital.  He will threaten you that you have inadmissible evidence that was obtained illegally.  You can then ask him or her rhetorically, "Can you please recognize that I am trying to make peace here?"  If he or she doesn't shape up immediately, look him or her squarely in the eyes and calmly ask him/her, "Do you think this evidence is admissible on 60 Minutes on CBS?"  He or she, too, will get weak in the bowels and become very silent.  
   
      Then, let it percolate.  They will have a lot of meetings and internal arguments.  They will then ask you what you want.  The answer to this question is simple:  You want them to comply with the law, and explain to the whole medical staff what is required by federal law.
   
     If you have to sic 'em, you should go to the feds and the print media at the same time.  This will force the feds to give this high priority, and the print media will let the hospital comply without the disgrace of having your videos on TV immediately.  Your trump card is television, of course.
   
     My wife won a federal case about overtime pay.  I won a federal case over fair housing (that never went as far as court).  When you are on the right side of the law, and get the backing of the federal government, you will not lose.  The hospital is not going to outlast/bankrupt the government in federal court.  About 3 months into the legal battle it will dawn on the hospital that they can't intimidate Uncle Sam and they will capitulate.  
   
    Hope it helps,
   
         Jeff, Tampa
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    Thanks Andy, Jeff, David...
   
  This type of thing happens everyday in my clinic and I get so exasperated
at the cases that
come my way that have been thrown away by the rest of
the medical community.
Just Thursday a wife called and told me her husband
who has COPD (emphysema) went to the
ER because he was SOB (short of breath) and getting worse by the minute.
  While there and in
respiratory distress he was told that they would not
admit him because they
did not want the staff to catch what he had.  Well
excuse me, but when was
the last time that COPD and Emphysema  was catching?  He
was discharged and
went home, still in resp distress, so wife called me and
I told her to bring
him over and I'd see about getting him admitted to
another hospital 20 miles
away (because we - NPs - are not allowed to admit our
own patients to the
hospital or care for them either unless we have a doc
to sign off on our
records every 24 hours (this hosp. rules, run by the
docs)).  When they came
to the office his color was dusky, lips purple as were
his fingertips, resp
30 a min and not exchanging in lower lobes.  I called
the ambulance service
to come and pick him up to bring him to the other
hospital after I called my
collab doc and gave him the scenario and he agreed to
admit him to the other
hospital.  Right after I called the amb service the
wife comes to get me
with a sense of urgency and sure enough when I go back
in the room he is
breathing about 40 times a minute and losing ground
fast.  The amb guys
arrived and put a non-rebreather mask on him and got a
pulse ox (ours broke and
I haven't been able to buy another one yet) which was
80%.  Then he
crashed, went into resp. arrest, seized - we got him
back and they
transferred him to the same hosp who had turned him
away because it was the
closest.  I thought surely he would die but he's still
hanging on very
confused.  They admitted him then of course.  

You see why I am so aggravated?  Things like this
happen every day - we get
2 or 3 emergencies a week and deal with them on top of
seeing everybody else
who is very ill and uninsured.  We get at least 75 walk-ins a day on
top of our
appointments and a good 275+ phone calls a day for
appointments and there's
one of me and we take the worst and do so on a daily
basis.  Where is the
conscience of these medical people who turn these
people away?  I don't know
but I couldn't sleep at night if I were them making
those decisions.

       
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