Hospitals and the Open-door Transfer Policy: Can We Do a Better Job?

Several weeks ago I was presented with a CT scan on a new patient, a young woman with a severe headache who had been transferred overnight by air ambulance from another hospital. As a center that specializes in diseases of the nervous system, my facility, the Barrow Neurological Institute (BNI), routinely accepts people from around the country. And since this woman had been sent to us because the CT scan from the outside facility was interpreted as her possibly having blood in the brain, no further questions were asked. Sounds like responsible and compassionate healthcare, right? But there was a hitch: The patient didn’t need to be transferred at all.


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The CT scan had been misinterpreted. The “hemorrhage” was actually calcium, a well-known normal variant. The woman was discharged from our facility a few hours later. Happy ending? Not when the medical bills start coming at 6 to 8 weeks. With two hospital admissions and a helicopter ride, she or her insurance are likely to be on the hook for something close to $70,000. Unfortunately, patients like this one are transferred to my hospital (and many other hospitals throughout the country) every day. And with 30% of bankruptcies in America caused by medical expenses, it looks like this young woman’s financial health will now be in significant jeopardy.


Why Doctors Don’t Question Hospital Transfers


This story is typical, and both the fragmentary nature of healthcare and government policy contribute to the problem. Fearing the worst (in this case blood in the brain) an emergency room physician hits the panic button, transferring the patient to a specialty hospital. The doctor is doing what they think is best for the patient—irrespective of cost. At the other end, the center of excellence accepts the patient, no questions asked. Doctors have been trained to do this. In most cases refusing a transfer is against hospital policy.


So why is the transfer not questioned? Most centers of excellence—university hospitals and specialty institutes—view themselves as the place of last resort. At the BNI, for example, our mission is to care for the most difficult neurologic cases. This is the position of most university hospitals and other centers of excellence, one that is reinforced by federal guidelines prohibiting hospitals from turning patients away in their time of need. Professional ethics also enters into the mix. At a provider level, the accepting physician doesn’t want to question (or challenge) the judgment of the outside doctor. In the end, accepting a transfer is far easier than not accepting it. And while financial concerns are secondary, there is still a general perception that more business—more patients—is a good thing. Why not accept the transfer?


Telemedicine: An Alternative to Costly Hospital Transfers


Historically the phone has been the only option for communication between hospitals. With no other information, the open door policy made sense. But times have changed. Just as you can Skype with friends over long distances, expert care can also be delivered remotely. Such advances are extremely important for credibility between providers and between providers and patients. Video improves relationships and credibility in the care cycle. Enabled by video (a primary tool of telemedicine), centers of excellence could complete their mission, support the outline facility, and still be more selective in which patients they accept for transfer.


This business model has worked effectively for telestroke treatment. Rural emergency room physicians weren’t comfortable initially with the administration of clot busting agents (t-PA) for stroke. But through the use of telemedicine, stroke experts now stand behind rural physicians, helping them decide whether or not to administer t-PA and whether or not the patient is to be transferred. This partnership allows patients to receive a higher level of care, while the number of transfers has diminished. It’s a win-win for both rural hospitals and urban centers of excellence. The same change in process, replacing the phone with video, is widely applicable to all sorts of clinical scenarios.


The healthcare community is built on principles of compassion and a chance to heal. But well-intended efforts that make it easy for patients to get care at tertiary facilities have unintended consequences. Care decisions need to be gauged against the ultimate outcome for our patients. Of course we need to take care of those patients who need tertiary services. However a blanket open-door policy for transfer may not be the right answer in 2016. To save someone who didn’t need saving, while ruining their financial health in the process, is not just a matter of outmoded policy; it is something close to a crime of neglect.


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