Many Factors Influence Treatment of E.R. Patients.

A person calls 911, paramedics arrive within minutes and rush him to a hospital. But what happens next?

Hospitals are required by federal and state law to assess a patient's condition and stabilize those in life-or-death situations, regardless of insurance status.

After that, the rules aren't so cut and dried.

The severity of the injury, the patient's insurance status, the hospital's facilities, even the time of day can play a role in what happens when a patient arrives at a hospital ER.

In cases in which a patient is transferred, the most frequent reason is money - more specifically, insurance and physician reimbursement.

"(A patient's fate) is most influenced, I would say, by how the (health care) system is organized," said Dr. Bruce Spurlock, executive vice president of the California Healthcare Association, an advocacy group representing hospitals, health systems and physician groups. "Where the doctor practices is a major determinant (for insured patients). If you're uninsured and don't have a doctor, you're going to have a lot more difficulties, and how you get cared for is going to be a lot more fragmented."

Typically, an insured person having chest pains calls the paramedics, is taken to an emergency room and is examined and stabilized. If the patient's cardiologist works at a different hospital, the two facilities typically coordinate a transfer. "That's probably one of the more common scenarios," Spurlock said. "That happens a lot."

But dealing with insurance companies isn't always that easy.

"It's more complicated with insured patients because the insurance companies may impose a bunch of constraints. They might limit the diagnostic work-up or treatments outside their network," said Dr. Brian Johnston, chairman of the L.A. County Medical Association and an emergency physician at White Memorial Hospital in Los Angeles.

Insurance companies also indirectly affect how an emergency-room patient gets treated because medical specialists are prickly about reimbursement rates.

Because physicians have experienced delays in getting reimbursed by insurance plans, many doctors have been refusing to come in when they're on call. And if a specialist on call won't report for duty, the patient must be transferred to a hospital where such a specialist is on duty.

"Transferring goes on all the time," said Virginia Hastings, emergency medical services coordinator for Los Angeles County. "More and more (transfers) are going on because the emergency department and the hospitals cannot get specialists to come in (to the emergency room). That is probably the biggest looming problem in this county right now, and in the state."

Another complication is that, in many cases, the specialist on duty is not a participant in the patient's health plan.

"(The hospital) may not have called a physician associated with the health plan that the patient has. ... Then it's a question of how much is the doctor going to be paid," said Walter Zelman, president of the California Association of Health Plans. "So the physician may not be satisfied with what the health plan is willing to pay. You can see a problem area."

While the friction between insurance companies and doctors can squeeze insured patients, uninsured patients have their own set of issues. After a medical assessment and stabilizing measures are taken, an uninsured patient brought to a private hospital's E.R. could be transferred out to a county hospital. Or not.

"County hospitals treat all comers until they fill up. If you come into a county hospital, you are going to be treated the same if you're uninsured or insured," said Jim Lott, executive vice president of the Healthcare Association of Southern California.

That means county hospitals frequently get indigent transfers from private hospitals' emergency rooms. A budget proposal this year by L.A. County Chief Administrative Officer David Janssen would have restricted transfers to just those patients for whom a county facility could provide better care. But Janssen, amid political and industry pressure, withdrew the measure from the county's budget, which was passed in June.

Even without the law, "the county is not obliged to accept a transfer, except when it's a higher level of care than the hospital that received the patient is able to provide," said Lott. "If the county declines, the (private) hospital is required to keep him."

While money considerations affect how and where a patient is treated, not all considerations are financial.

"Many private hospitals are teaching hospitals as well, and will take some cases that are indigent because it's good for the training of the staff there," Lott said. "Also, private not-for-profit hospitals have a charity care obligation they must meet to maintain their tax-exempt status."

Experts stressed that care is the top priority and assessing and stabilizing a patient must be done for all patients. But care for a non-emergency patient, such as one with a sore throat and sniffles, brings its own factors.

"If it's in the middle of the night, that patient is seen, but they're put in that queue along with all the gunshot wounds that come in," Lott said.

But patients should not worry about being sent back out the emergency-room door. Due to strict federal laws, a patient may not be released or sent elsewhere without a preliminary exam.

"(Hospitals) are subject to a $50,000 fine if the hospital 'dumps' a patient because he or she doesn't have insurance to cover it," Lott said. "It's not so much the fine, it's the reputation and the licensing and accreditation of the hospital. If that happens, your license can be threatened, and the most immediate problem is the loss of your Medicare certification."