A few years ago, Marcela Flachsland’s family learned her then 77-year-old uncle had advanced pancreatic cancer. 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 their 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 acute care 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.”
You can choose your care location
“The benefit of American health care is that patients are empowered to choose where to receive care – even in an acute event,” says Russell Graney, founder and CEO of Aidin, an online platform that helps connect providers, patients and payers to improve health care outcomes.
“Patients are often unaware that they can change hospitals – or are told by the staff that it isn’t possible,” adds Julia Hallisy, founder and president of the Empowered Patient Coalition.
Arthur Caplan, a professor of bioethics and founding head of the division of medical ethics at NYU School of Medicine in New York City, agrees. Patients absolutely have the right to transfer to another hospital, he says. However, the impetus for action – getting a second hospital to agree to take the patient – falls to determined families.
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 and associate professor in the department of medicine at NYU Grossman 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.
“While practicalities like distance, insurance coverage and the hospital’s ability to provide the necessary care govern most decisions, if a patient or family feels their loved one isn’t receiving the care they need, it’s essential to speak up, advocate for yourself and if necessary, transition your care to another team,” Graney explains.
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.
Difficult situations like what Flachsland described crop up now and again for families across the country, and these experiences are nearly always emotionally fraught and usually urgent. Such situations tend to arise when the relationship between patient and provider has been damaged in some way.
What to consider when thinking about a transfer
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.”
Transferring from one facility to another isn’t always easy. There’s no magic “transfer now” button you can push to set events in motion, and there’s no overarching authority or central agency you can turn to for support in making a transfer happen.
But that doesn’t mean there’s nothing you can do.
When considering a transfer, “the first and most important thing to nail down is where you’d like to transfer,” Graney says. “Your care team first will need to find an accepting physician at your new hospital to ensure you’re landing in a safe environment that’s ready to take on your needs.”
In determining this best location, think about quality and whether the hospital you’re considering transferring to can offer any better care than what you’re already receiving. “Quality of care should be every patient’s first priority, and only a patient and family can jointly assess if the current team’s approach is going to work,” Graney says.
Indicators of a hospital’s quality include:
- Number of falls.
- Rate of hospital-acquired infections.
- Timelines and effectiveness of care.
- Efficient use of testing.
- Rehospitalization rates.
“An observed increase or deviation from normal in any of these indicators may be a reason for conversation with the care team and an eventual transfer,” Graney says, noting that it’s not just about clinical numbers. Health care is also “about healing. If you lose faith in your care team, it’s best for everyone involved to get you connected with the right team to promote your healing.
Requesting a hospital transfer
To initiate a transfer, reach out to your hospital case manager or social worker, as these professionals “are committed to advocating for you and your needs,” Graney says. “They’re experts in the health care system and know how to navigate its many complexities.”
And be sure to “explain your concerns calmly and plainly and know they’re there to help you get what you need.”
He adds that “most case managers will have experience supporting patients in tricky situations and will offer counsel and advice given the specifics of your case.”
You should also contact your insurance company for details about any costs or fees you’ll be expected to pick up in executing a hospital transfer. Graney recommends contacting a case manager at the insurance company to walk you through the particulars depending on your specific coverage plan. Transportation costs are often not covered, and these “can be quite expensive, especially when more advanced ambulance services are needed.”
Some insurers also require proof of medical necessity or a physician’s approval.
You’ll also want to determine whether the facility you’re transferring to is in your insurer’s network. “Some insurance plans will cover out-of-network hospitals to a limited degree, and others may not do so at all,” Graney explains. Make sure you understand your financial responsibilities before you take the plunge on a transfer.
You should also consider other, less tangible costs. “The biggest cost can be a cost to your health,” Graney says. “Ensuring the accepting facility is ready to deliver the needed care is most important, so your care and recovery aren’t negatively impacted by your transfer.”
Your transfer isn’t guaranteed
Even if a patient does choose to leave the hospital where they’re being treated, there’s no guarantee that the hospital you prefer will have a bed available 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 national philanthropy engaged in independent research on health and social policy issues. Such a physician is thoroughly vetted by the privileging hospital, says Blumenthal.
When the need for a transfer is under question, Blumenthal says, various individuals are involved, including the patient and their family, the patient’s physician of record, the current attending physician and the potential admitting physician from the desired new hospital. The medical discussion considers 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 patient.
The bottom line is that patients can ask their preferred hospital to be admitted, but the hospital doesn’t 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 undertake 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 for help
If your transfer request has been turned down, you can appeal the refusal. These are some steps you can take to support that effort:
- Meet with the hospital’s ethics committee. 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.
- Appeal to the chief medical officer. If the ethics committee doesn’t work out, Caplan says, “I would go straight to what’s called the chief medical officer. There’s always somebody who’s the top dog at a place.” That person may have the authority to overturn decisions made by others in the hospital.
- Speak with a patient advocate or ombudsman. These individuals work in the hospital and can act as the liaison among patients, providers and insurers to work out issues and concerns. 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.”
- Hire a lawyer. You can opt to work with a lawyer to pursue your rights. 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 Richard Lovich, an attorney and co-managing partner of the Law Offices of Stephenson, Acquisto & Colman, a health care litigation law firm representing patients and the health care provider community in Burbank, California.
- Recruit the assistance of a medical expert. 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.
- Contact a quality improvement group. If you have Medicare, Lovich 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 that may be able to assist you. You can locate a QIO to contact in your area.
- Request an exception from your insurer. If your insurer’s out-of-network restrictions are a barrier to transferring, you can request an exception. America’s Health Insurance Plans, or AHIP, a national association of health insurers, 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.” The process then involves documentation of medical necessity and review of the request by the plan’s medical directors.
Making peace with the outcome
For Flachsland’s uncle, the requested transfer never happened. His condition rapidly deteriorated, 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.
For some other patients, transfers can be a really positive thing, Graney says. “Transferring care isn’t only for when something isn’t going right. Almost every health care journey includes transitions from one provider to the next. Hospital patients, for example, often need follow-up care after surgery or a serious illness.”
And moving you safely and securely on to this next level of care is “one of the essential services your health care team should provide,” Graney says.
Anytime you’re choosing a new provider for any level of care, he recommends considering the following questions:
- Is this the best quality provider, or the most convenient?
- Did my doctor refer me here for clinical reasons or because there are business incentives at play?
“These transition moments play a critical role in health outcomes. They also determine where our health care dollars are spent and what types of providers are rewarded with more referrals or fewer.”