Experts spell out which rights patients do and do not have related to transfer requests and offer potential avenues for families who want to persist in seeking better care.
When you — or a loved one — are being treated in a hospital that you don’t really trust, and the hospital doesn’t cooperate with your transfer request to the hospital you want, it’s a nerve-wracking time. As the patient, there’s no magic “Transfer Now” button you can push to set events into motion. And, there’s no overarching authority or central agency to step in and make a transfer happen.
Below, experts spell out which rights patients do and do not have related to transfer requests and offer potential avenues for families who want to persist in seeking better care.
Right to Leave
“Patients are often unaware that they can change hospitals — or are told by the staff that it isn’t possible,” says Dr. Julia Hallisy, founder and president of the Empowered Patient Coalition.
When a patient has to remain in the hospital under protest, the family, friends or medical agent should ask for a social worker or patient relations professional to step in as an intermediary between all parties, Hallisy advises. “Usually,” she says, “by the time a family wants to change hospitals, there has been some type of issue involving a breakdown in communication.”
It’s a “medical urban myth” that leaving a hospital against medical advice will get a patient into trouble with insurers and billing, says Dr. David Alfandre, a physician and health care ethicist at the NYU School of Medicine who has done extensive research on AMA (against medical advice) discharges. Physicians shouldn’t exaggerate AMA consequences to discourage patients from leaving, he adds.
Looking for Better Options
In September 2016, Marcela Flachsland’s family was shocked by her uncle’s new diagnosis of advanced pancreatic cancer at 77. Her early impression of the New Jersey acute care hospital where he was a patient was one of confusion and conflicting information from the medical staff. The family felt her uncle’s interests would be better served in a cancer-focused facility.
They sought a second opinion from the nearest branch of a renowned cancer center. A physician told Flachsland’s aunt they could treat her uncle with chemotherapy. However, doctors at the current hospital insisted a transfer would be too difficult for the weakened patient and that moving him was not a medical necessity.
“As a relative, you want to do everything possible,” Flachsland says. “You’re just trying to find other options. My aunt was devastated and frustrated and she didn’t know what to do.”
No Right to Be Admitted
Flachsland’s uncle had the right to leave the hospital at any time — at least in theory. But he was frail, ailing and in pain. If he were transferred, insurance complications meant his wife would have to pay ambulance and other transfer costs. While costs vary among counties and states, low-ball fees for an ambulance providing advanced life support range from about $500 to $650, plus mileage costs at roughly $13 per mile. But the ride and transfer can cost much more, as waiting-time fees and other services add up.
“I understand that if he wanted to, he could refuse treatment in that hospital, and he could just go out and then nobody would be responsible for him,” Flachsland says. “You don’t want to carry that on your shoulders.”
Even if a patient does choose to leave, there’s no guarantee that the hospital you prefer will have an available bed or be willing to take you as a patient. You can’t just check yourself in.
“You have to be admitted by a professional with admitting privileges,” says Dr. David Blumenthal, president of The Commonwealth Fund, a private foundation with the goal of improving U.S. health care policy and practice. Such a physician is thoroughly vetted by the privileging hospital, say Blumenthal, who most recently practiced at Massachusetts General Hospital.
In his experience, Blumenthal says, when the need for a transfer is under question, the chain of events includes the patient, family, the patient’s physician of record, the current attending physician and the potential admitting physician from the desired new hospital. The medical discussion takes into account related scientific evidence and the patient’s diagnosis and condition to determine whether a transfer is medically justified or needed. This medical advice is conveyed to the hospital managers to guide their decision, which is then relayed to the patients.
The bottom line is that patients can ask their preferred hospital to be admitted but the hospital does not have to agree, especially if it has nothing unique to offer — such as a specialized burn unit for a severely burned patient, for instance, or the capability to do advanced cardiac surgery when needed.
Blumenthal has empathy for patients whose admission requests are turned down. “I can see how they would feel disempowered and frustrated and denied a right they think they have,” he says. “But the institution also has rights to protect its resources, to steward its resources and to keep its resources available to people who can benefit.” He concludes, “It’s a matter of conflicting rights, not just a patient right.”
Where to Turn
You do have the right to question a transfer refusal. These are some steps you can take:
Ask for a meeting with the hospital’s ethics committee, Caplan suggests. All hospitals are required to have one. If appropriate, the committee can direct and advise that the transfer be allowed.
If the ethics committee doesn’t work out, Caplan says, “I would go straight to what’s called the chief medical officer,” he says. “There’s always somebody who’s the top dog at a place.”
You can also try the hospital’s patient representative. However, Caplan says, “They tend to work a little more for the hospital and be a little less independent than the ethics committee might be.”
You could hire a lawyer. Families already struggling to keep up with medical bills might seek free or reduced-cost legal services. “There’s a lot of great pro bono activity out there to represent a patient,” says attorney Richard Lovich, a partner with the law firm Stephenson, Acquisto & Colman in Burbank, California.
Lovich, who specializes in health care reimbursement litigation, says hospitals want to do the right thing. “If somebody needs a service, and your hospital is unique in that they provide that service that nobody else does, I’ve honestly never run across a situation where a hospital has refused a patient delivery of those services because they couldn’t pay for it,” he says.
To facilitate a disputed discharge and get into your hospital of choice, it helps to have a medical expert, along with loved ones, on your side. “We often recommend involving your family member and primary care physician,” Alfandre says. A patient’s regular doctor can help identify possible options and encourage more rapid follow-up with treatment and transfer decisions. “Involving people who know the patient well often helps improve the outcome,” he says.
For people with Medicare, Lovich also suggests turning to a quality improvement group. QIOs are private organizations made up of teams of physicians and other experts in health care quality and regulations. You can locate a QIO to contact in your area.
If your insurer’s out-of-network restrictions are a barrier to a transfer, America’s Health Insurance Plans, or AHIP, an industry trade group, explains conditions for exceptions:
“In the rare instance where there is no appropriate facility within the plan’s network that can meet the unique medical need of the patient, a health plan’s exceptions process can be triggered by the covered member — or more typically their current provider on their behalf — to allow for covered benefits to be provided by an out-of-network provider,” AHIP explains in an email. The process then involves documentation of medical necessity and review of the request by the plan’s medical directors.
The transfer never happened for Flachsland’s uncle. His condition took a rapid downturn and he began receiving hospice services, first at a nursing home and then back at the same hospital. Communication between the family and treatment team improved somewhat.
“We finally had a conversation with the oncologist,” Flachsland says. “He sat down with us and said there’s really nothing else that can be done. A transfer is just not a good idea.” Within two weeks, Flachsland’s uncle died.
Months later, Flachsland looks back on the hospital’s response. “I know that probably they were right and probably nothing could be done,” she says. “But I feel that you need more heart when you’re giving this kind of news. Only later did we get some answers.”