Check Your Privilege -- Dispelling Misconceptions About Abortion Care and Hospital Admitting Privileges

Rebecca E. Cooney, PhD

Disclosures

March 22, 2016

Editorial Collaboration

Medscape &

With scholars and media alike calling it the most important reproductive rights case in a decade, the US Supreme Court justices convened on March 2 to hear arguments for Whole Woman's Health v Hellerstedt. At issue is whether a 2013 law is in opposition to the 1992 precedent that prohibits states from enacting legislation that puts an "undue burden" on a woman's right to choose.

What makes this a particularly salient case for the medical community to consider is the notion that the law at the center of the case, the Texas Omnibus Abortion Bill 2 (H.B. 2), was designed to protect patient safety and women's health. Specifically, H.B. 2 outlines two central provisions: that clinics must conform to the standards of ambulatory surgical centers and that abortion clinics must have doctors on staff with admitting privileges at a hospital within 30 miles of the clinic.

Although it has not been the central focus of much of the coverage of the case to date, the issue of admitting privileges is integral to determining the legitimacy of the claim that H.B. 2 is an improvement on patient safety for abortion care or an attempt to restrict access to abortions by creating unnecessary standards for providers. But does the legislation reflect the reality in how admitting privileges actually work?

It is on this point that the Society for Hospital Medicine (SHM) and the Society of Ob/Gyn Hospitalists (SOGH) elected to submit an amicus brief to the Supreme Court to clarify what they felt were important gaps in information about the process of admitting patients and the potential role of hospitalists and hospitals in postprocedural abortion care.

In the context of the current case, Dr Ron Greeno, chair of the public policy committee for SHM, says that hospitalists, "have significant input that might be helpful to the Court in terms of how inpatient and outpatient care, and the interphase between those two, has changed over the past few decades in the United States, as well as to clear up any misconceptions that may have been stated by either side regarding that dynamic." To that end, the amicus brief offers three areas of explanation and clarification.

1. Hospitalists Are Specialists in the Practice of Medicine in the Hospital Setting

Hospitalists, most of whom are general internal medicine doctors, function as the primary providers of care for hospitalized patients and serve to facilitate the transition between the clinic and primary care to inpatient hospital care. The number of hospitalists is growing, with more than 44,000 physicians in the country who care for about half of all patients in hospitals. An important distinction between hospitalists and other physicians is that hospitalists specialize in admitting patients, coordinating medical care in the hospital, and comanaging patients with other specialists, such as surgeons. Of note, even the majority of doctors staffing hospital emergency departments do not themselves have hospital admitting privileges—a fact that legislators may not be considering.

2. Requiring Physicians Who Specialize in Outpatient Procedures With Low Incidence of Postprocedure Complications, Such as Abortion, to Have Admitting Privileges Is Inconsistent With the Modern Practice of Hospital Medicine

In the setting of abortion care, the stipulation of requiring admitting privileges is a clearly an incongruent one. In regard to hospital credentialing, admitting privileges are specific to the clinical services and expertise that a physician has. In the case of physicians who specialize in outpatient procedures, admitting privileges are not necessary to provide care, nor do they reflect a physician's competence or skill at providing that care.

"There is a huge percentage of physicians in this country that are providing outpatient care with high quality and with good continuity, who do not go to the hospital anymore," Dr Greeno maintains.

"A hospital's decision to grant and/or not to grant an outpatient provider admitting privileges is not in any way a proxy for that provider's competence as a medical provider in another setting. It is not appropriate, in our eyes, to conclude that a provider is capable or incapable on the basis of a hospital credential committee granting that provider admitting privilege. Requiring admitting privileges for physicians does not enhance the quality of care in outpatient settings—it is unrelated. The assumptions that have been drawn by some of the participants in this case around that issue are erroneous and obsolete."

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