Dr. Dale Carrison, head of emergency services at the taxpayer supported University Medical Center, has read some of the discharge documents that dialysis patients bring with them from for-profit hospitals in the Las Vegas Valley.
They instruct the patient, who is uninsured and usually an illegal immigrant, to go to UMC for follow-up care.
"It is clear that the patient needs more dialysis, and it is also clear that they don't want to take care of it because of the cost," Carrison said of the other hospitals. "It offends me that people offering care for profit would condone or do that."
Last weekend, the Review-Journal reported that cash-strapped UMC is providing more than $20 million a year in emergency dialysis care for uninsured, illegal immigrants.
This week, when Sunrise Hospital and Medical Center announced the layoff of 100 workers, it became apparent that care for the uninsured also affects for-profit health care institutions.
According to spokesman Dan Davidson, Sunrise provided $110 million in uncompensated care in 2008, including nearly $1 million in emergency dialysis care for illegal immigrants for January through July this year. Davidson said that is part of the reason layoffs occurred.
Under federal law, anyone who shows up at an emergency room requesting an examination or treatment for a medical condition must be given an appropriate medical screening to determine whether there is an emergency. If there is, treatment must be provided regardless of a patient's ability to pay or their citizenship.
Officials at UMC, which provided $160 million in uncompensated care in 2008, and Sunrise said they don't know how much of their total uncompensated care for the uninsured goes to illegal immigrants. Under federal law, hospital staff cannot directly ask patients whether they are in the country illegally.
U.S. citizens with end stage renal disease automatically qualify for Medicare to cover dialysis costs. Illegal immigrants are not eligible for Medicare. As a result, patients who have neither insurance nor Medicare to pay for dialysis are almost exclusively illegal immigrants, a distinction that allows hospital officials to estimate costs for their care.
The Sunrise layoffs come as the trade magazine Modern Healthcare reports that HCA, the Nashville-based parent of Sunrise and the nation's largest hospital chain, doubled its profits in the second quarter, with revenue increasing to nearly $7.5 billion.
"We had to do the layoffs to stay competitive," said Davidson, who said he could not reveal whether Sunrise was operating at a loss. "We had to reduce our cost structure to remain competitive with other hospitals in the area."
Spokeswoman Ashlee Seymour said the Sunrise Health System, including Sunrise, Sunrise Children's Hospital, MountainView and Southern Hills hospitals, isn't steering illegal immigrants to UMC.
She said there were 54 patient visits by illegal immigrants for emergency dialysis care in a seven-month period this year. That cost the hospital about $15,000 per patient.
But Carrison said it is possible that physicians at for profit hospitals have been sending patients to UMC on their own.
"They may not want to deal with them, or they may think the hospitals where they practice don't want that kind of patient," he said.
Suzie Wood, a spokeswoman for the Valley Health System, refused to divulge how much dialysis care for illegal immigrants is done at either Valley or its other facilities, Desert Springs, Spring Valley, Centennial Hills and Summerlin hospitals.
"I can't get that information," she said.
Wood said it is possible that Valley Health System staffers at emergency rooms may ask individuals requesting dialysis whether they would rather go to UMC.
"They may have a friend there," she said. "We give them an option. It really depends on the person."
Carrison said he does not recall seeing illegal immigrant patients being sent to UMC for dialysis from the St. Rose Dominican Hospitals. A St. Rose spokesman, Andy North, said such care has been provided, but he wouldn't say how often it is done or at what cost.
Carrison said UMC's situation may be improving.
Recently, he said, UMC CEO Kathy Silver met with other hospital CEOs in the Las Vegas Valley. In the last month, he said, he has not seen illegal immigrants sent by other hospitals to UMC for dialysis.
"She made it clear that this is not just a UMC problem," Carrison said.
Three illegal immigrants who last week were receiving dialysis care at UMC told the Review-Journal they went to the publicly supported hospital because they heard from people in the community that it offered the treatment to anyone.
Dialysis is almost four times more costly when done through the emergency room than through the usual doctor-guided treatment at a dialysis center.
Carrison said illegal immigrants with failing kidneys figured out doctors will treat them if they go to the emergency room "in bad enough shape."
The billed costs at UMC can run from $11,000 to $18,000 per visit because of required testing and added care that often requires costly in-patient treatment to keep them alive, UMC officials said.
Most dialysis patients must go two or three times a week.
Charles Duarte, head of the Medicaid division of the state Department of Health and Human Services, said Wednesday that Medicaid payments can be made to hospitals when dialysis for illegal immigrants is a true emergency. But state reviewers often characterize the visits as "regular chronic care," so hospitals aren't reimbursed.
In 2008, the state reimbursed UMC for about $230,000 for emergency dialysis while UMC estimated the costs at $14 million. That reimbursement is less than 2 percent.
"We have a different definition for emergency," said Brian Brannman, UMC's chief operating officer. "Our doctors think these patients will die and they (state officials) don't."
Duarte said Medicaid payments of about $3,700 for emergency dialysis were made in 2008 to two St. Rose Dominican hospitals, and a $3,000 payment was made to Sunrise Hospital. No Valley Health System hospitals received Medicaid payments in 2008, he said.
If health care professionals at UMC or any other hospital choose to do so, they could report illegal immigrants to U.S. Immigration and Customs Enforcement.
But, Brannman said, "you're not going to get health care folks to do that. Physicians and nurses are focused on the patient. That's what their oaths are about."
"That may not be something that people want to hear. But you're not going to solve this problem through doctors and nurses. ICE agents could take a walk through any emergency room in America if they wanted to and make arrests."
Carrison, a former FBI agent, agrees. "I'm no longer in law enforcement. It's time for ICE to take some initiative. It's not up to me as a physician to be a law enforcement officer."
Rep. Shelley Berkley, D-Nev., said Wednesday that health care professionals should not be working as law enforcement. "They have a big enough job to do caring for patients," she said.
UMC spokesman Rick Plummer said it takes ICE several weeks to deport somebody.
"And they don't want to eat the costs of providing medical care during that time," especially with a chronic condition like dialysis, he said.
Lori Haley, a spokeswoman for ICE, said the agency uses several investigative tools to arrest illegal immigrants. She said the agency works on priorities but would not disclose how high illegal immigrants who are getting health care rate as a priority.
UMC's problem isn't going away soon. Emergency room physician Christian Young said the hospital is giving two new illegal immigrants dialysis care since the Review-Journal's report on the issue.
"They heard in the news that they could get it at UMC," he said. "Guess we have a long battle ahead of us."
Contact reporter Paul Harasim at email@example.com or 702-387-2908.