In this episode, attorney Christopher Mellino of the Mellino Law Firm discusses a hidden crisis unfolding in Ohio’s community hospitals. Chris explains how decades of hospital mergers and service consolidations by major systems like Cleveland Clinic and University Hospitals have stripped local facilities of critical services such as labor and delivery, neonatal intensive care, and cardiac units. These cuts, he argues, have led to tragic delays in emergency treatment and preventable injuries and deaths. The conversation explores the legal obligations hospitals have under federal EMTALA law, the real-world impact of delayed transfers, and what Ohio families can do to protect themselves and advocate for transparency and reform in their local healthcare systems.
John Maher: Hi, I’m John Maher, and I’m here today with Christopher Mellino, founding attorney of the Mellino Law Firm, a personal injury law firm in Cleveland, Ohio, with a focus on medical malpractice. Chris has over 40 years of experience in handling medical malpractice cases, has been involved in several landmark cases in Ohio, and has received verdicts against every hospital system in Cleveland. Welcome, Chris.
Christopher Mellino: Hi, John. How are you?
John: Good, thanks. So, Chris, today, we’re talking about a hidden crisis in neonatal and emergency care, specifically relating to community hospitals and some changes that have happened. What patterns have you seen that have connected hospital cost cutting and service consolidation to preventable birth injuries and emergency room tragedies here in Ohio?
Chris: Yeah. Well, first, let me say, John, it’s good to see you again, and happy to be part of the podcast. I hope you don’t mind, Maple, I guess, decided to join us this morning.
John: Yeah. Your office dog?
Chris: He’s our new office puppy, yeah.
Hospital Cost Cutting and Service Consolidation
Chris: So people that live in the Greater Cleveland area are pretty familiar with the fact that over the last 20 to 25 years, the Cleveland Clinic and University Hospitals have competed with each other, buying up the local community hospitals. And so, when I was growing up, and up until about 20 years ago, people were able to get pretty much any hospital service in their own community, a short drive from their home. People were able to come and visit them if they were in the hospital.
And then, like I said, University and Cleveland Clinic started buying up these community hospitals, and also local doctor practices, and funneling all that medical care downtown to their main campuses which, as you referred to as “consolidation of services”, meaning that they were able to then only provide those services at one location.
And so, now, instead of getting the services in your local community, you have to go down to their downtown campuses and get the care there, which most people wouldn’t choose to do, and it has resulted in…it hasn’t reduced cost at all. There are studies to show that, but it also poses a lot of risks to patients.
Risks of Hospital Cost Cutting
John: And what’s involved in those risks? Why does that potentially put babies and mothers at risk?
Chris: Well, I mean, the most obvious place where the risks manifest themselves is in the emergency room, because people go to the emergency room because they need care in a hurry. There’s a lot of situations where there’s a window of time to treat the condition that somebody might have, like a stroke or a heart attack. I’m sure people have heard phrases like, “time is muscle,” when it comes to a heart attack, meaning the longer your heart goes without blood, the greater the damage is going to be to the heart.
Same thing with the stroke. “Time is brain.” Same idea. Your brain goes without oxygen during a stroke. The longer that goes on, the more damage you’re going to have. One of the most frequent services that are removed from community hospitals are labor and delivery. And most of the time, fortunately, labor and delivery goes well, goes smoothly. There’s no issues. But when there are problems, the baby is not getting enough oxygen during labor, time is of the essence, and the longer somebody waits to provide that care, the more harm can come to the mom and baby.
John: Right. So if they don’t have those services there at that local hospital, then they have to do their best or they have to transfer them to another hospital, like downtown? Is that what’s happening? And then they’re losing time because of that transfer to another hospital?
Chris: Yeah, well, that’s a great point. I mean, you hit exactly on the issue, and that is, a lot of the emergency room doctors that we’ve taken depositions from don’t know the answer to that question. As you said, “do their best”, and we’ve taken depositions where doctors said, “Well, yeah, we just tried to do our best,” when the services, the equipment, the people that they need to provide specialty care just aren’t available in that hospital, and their best, no matter how good it is, isn’t going to be good enough, because those patients need to be transferred and they need to be transferred in short order, immediately.
And the secondary problem is that the hospital systems themselves have taken over the transfer of the patient. So it’s not as easy as just calling 911 or calling for an ambulance. They have to go through these channels, the transfer center. These hospital systems have their own transfer center. They have their own vehicles. They have their own personnel. And just like most things in a hospital, it’s a big bureaucracy.
So there may be other patients. There may be a problem with vehicle availability. But yeah, the short answer to your question is, yes, in a situation where the hospital systems have consolidated or removed labor and delivery or cardiac care or intensive care from community hospitals, those patients need to be transferred immediately as soon as they get to the emergency room.
What Duties Does a Hospital Have to Stabilize or Transfer You?
John: Right. When an expectant mother arrives at a community hospital and she’s in distress, what are the specific duties that the hospital has under Ohio and federal law to stabilize or transfer you, and where do you see that duty breaking down?
Chris: Some people are familiar with something called EMTALA, that’s the federal law that governs, and it basically doesn’t allow hospitals, if they don’t have insurance, to just transfer them out to some other hospital, to “dump them on another hospital.” So it’s called EMTALA. It’s an anti-dumping statute.
But the requirements under the statute are that a qualified medical provider, which is usually the emergency room doctor or qualified nurse practitioner or physician assistant, would examine the patient to make sure that they’re stable, meaning they’re not having some kind of crisis or, I mean, they’re in imminent danger of death or severe injury.
And as long as that’s not the case, then they can be transferred to another hospital. So let’s just take the case of a mother who comes in who’s pregnant and may be in labor. So labor is not an emergency medical condition. And just because the patient’s in labor, doesn’t mean they can’t be transferred.
John: Right, because it could take some hours sometimes before the baby actually comes out, right?
Chris: Yeah, it could take hours. Right. So those patients can be transferred. They just have to arrange for… In this case, what we’re talking about, consolidation of services, they just have to call down to the main campus to make sure that there’s doctors there that can take care of the patient, that are aware that the patient is going to be coming, and are ready for them when they arrive.
So that’s different than, say, [where the] patient’s been in labor for hours and then goes to the emergency room, and maybe delivery is imminent. If there’s a presenting part that’s coming through the birth canal, then that’s a medical emergency. And then in that situation, they do have to do the best they can to deliver the baby, but then they have to immediately transfer the baby to a hospital where there’s a neonatal intensive care unit.
John: Right. Yeah. I know my own wife with our first child was developing preeclampsia before the birth. So her blood pressure was going crazy, spiking, and there was danger to the baby, because the baby’s heart rate was going down. They had to do an emergency C-section.
Chris: Right.
John: So, I mean, those types of things could crop up at the last minute too. A mother could come in and seem totally fine, and just going into labor, and then they notice later that there’s some issue, and maybe it’s too late to transfer them then or something like that. Right?
Chris: Right. That’s exactly right. And most people think, “Well, this isn’t something that could happen to me.” But your example there is it could happen to anybody, that everything can seem fine. You can have a normal pregnancy all the way up and even be in labor and have a normal labor, and things can turn on a dime, can turn in a minute. And all of a sudden, you need emergency medical care.
So, I mean, when they take… I don’t think I mentioned this yet, but you brought this up — it’s a good point — is that when they take labor and delivery out of the community hospitals, they also take the neonatal intensive care. So the ability to do emergency C-sections, and then the ability to resuscitate newborn babies. Normally, if there’s an emergency C-section, the baby is going to need some resuscitation when he or she is born.
John: Yeah. Certainly my son did.
Chris: Yeah, so all those services are removed at the same time.
How Do Delays and Lack of On-Site Specialists and Equipment Translate into Liability?
John: Right. So we talked about how those minutes really matter, especially in these neonatal and cardiac emergencies. How do delays in diagnosis and a lack of on-site specialists and maybe equipment shortages translate into liability for hospital negligence and medical malpractice in Ohio?
Chris: Well, I mean, if they’ve consolidated the services — and most hospitals still hold themselves out in the community — most hospital systems hold the community hospital out to the public as, if you look on the website, they say, “Well, we’re the first full-service hospital.” And they list all the services they provide or “we can take care of”, certainly.
John: They say like, “Oh, if you’re having an emergency, come to us.”
Chris: Yeah, exactly right. So one of the things that has to happen is that there have to be policies and procedures in place in the hospital so that the people working there, the doctors and nurses, know which patients have to be transferred and which patients have to be transferred immediately. What’s the criteria for an immediate transfer? And they need to know the process, how to transfer the patient, to call the transfer center, how to arrange for the transfer. All those things have to happen.
And what we’ve seen in our cases, a labor and birth case and cardiac cases where these emergency room doctors aren’t hired by the hospitals. Most people don’t know this, but there’s agencies that provide the staffing for emergency rooms, for the doctors, that are separate from the hospitals, and they work at many different emergency rooms, what they call “take shifts”.
So they take shifts. Might be at Fairview Hospital one night. Two or three days later, it might be at Parma Hospital, could be at the downtown campus. So they move around. We had a situation where an emergency room doctor lived in Columbus and took a shift at a community hospital in Bellevue. And they don’t know. They don’t know what services are provided by that hospital. They’re not familiar with the policies and procedures.
So in the one situation in Bellevue, the person came there with 10-out-of-10 chest pain, sweating, all the classic signs and symptoms of a heart attack. Apparently, she didn’t realize that they didn’t provide cardiac services at that hospital. Instead of transferring this patient right away, because the hospital had no capability to care for him, she kept him there for observation for two or three hours, when the window to get that kind of patient to a cardiac catheterization lab is 90 minutes, and our client ended up suffering a major heart attack.
John: Oh, God.
Chris: Same thing happens with the labor and delivery cases. The emergency room doctor worked at three or four different emergency rooms in the hospital system and apparently was unaware they didn’t have labor and delivery at that hospital, and let the mother, who was clearly obviously in labor, doubled over in pain, they just left her in the waiting room for an hour and 20 minutes, and then she had a crisis and needed emergency medical care, and it was too late to transfer.
What Rights do Patients Have to Request a Transfer?
John: Okay. So many families, I’m sure, don’t realize that their local hospital has quietly downgraded its NICU or eliminated the NICU or eliminated certain cardiac services. What proactive questions should parents or patients ask upon arrival in the ER to perhaps protect themselves and their newborns or themselves? And what rights do patients have to request a transfer if they don’t think that the hospital that they’re currently at is suitable for what their condition is?
Chris: Yeah. And there’s no reason, in most cases, for people to suspect that the hospital no longer has those services, because, as we’ve talked about, they advertise themselves as full service, “Come here in an emergency. We provide a full range of care to a full range of patients, from birth to senior care.” And then most of those advertisements you see are for the hospital system, saying that, “We’ll provide excellent care for your baby.”
But in the case of, say, a pregnant patient, I mean, that’s something to discuss with, if you have one, an OB that you’re seeing regularly. And again, this was the case with our client. In her practice, there were OBs, and she was seeing midwives that were rotating or they were leaving the practice. So she didn’t really have any continuity of care. But it is something you should discuss early on in the pregnancy, is like, “Hey, if there’s ever an emergency, I live five minutes from this community hospital. Can I go there in an emergency?”
And then it would be up to the OB provider, whether it’s the doctor or the nurse practitioner, to say, “Well, no, that community hospital doesn’t have labor and delivery services. Here are some around you that do.” But in the case of the heart attack, I mean, there’s no reason to be asking ahead of time.
John: Yeah. You don’t know that that’s coming, unless you’ve got an obvious heart condition that, “I could be having a heart attack at any moment,” or something like that.
Chris: Right. Exactly right.
John: Yeah. It’s unlikely.
Chris: I mean, most people know what the signs of a heart attack are. So it’s worth asking if they have a cardiac catheterization lab. Do they have cardiologists on staff? Can you see a cardiologist? Yeah. You can always ask for a transfer.
John: Sure.
Chris: The problem is they don’t always have to transfer you.
What Policy Changes Would Most Effectively Reduce Ohio Birth Injury and Emergency Care Failures?
John: Right. So looking ahead, what policy changes or hospital system reforms would most effectively reduce Ohio birth injury cases and emergency care failures, and how can affected families help to push those reforms forward?
Chris: Well, I would say, there’s no good reason to be removing those services from community hospitals. There’s been studies that consolidating services don’t reduce costs, and they don’t improve the quality of care. So there’s really no reason to be doing it. So if you live in a community where there is a community hospital, I would do everything you could to fight to save it, and to resist any kind of removal of services from there.
John: Can the public just find out? Can they just call the hospital and say, “Hey, do you have these services? Have these been removed?” Can somebody who wanted to do some activism here reach out and find out what’s going on at their local hospital and then maybe try to get up some sort of grassroots thing to try to prevent this from happening or get those services back?
Chris: Well, John, I’ll be honest with you, they could do that, but I don’t know how transparent…I mean, hospitals are not very transparent. My guess is, if you did that, you wouldn’t really get a straight answer. I mean, obviously, you can do the research and see, but that may be beyond what most laypeople can do.
John: Right.
Chris: Again, I think the best source of information is your personal doctor, your internist, family doctor, whoever you see regularly, to talk about those things with that doctor. That’s the best place to get information. I mean, if you just call the hospital, you don’t know who you’re going to talk to or what they’re going to tell you, and I think most of them are pretty guarded. Most people that answer the phone there are pretty guarded as to what information they’re going to give the general public. They’d probably refer you to the website, which, again, doesn’t contain necessarily accurate information.
John: Any final thoughts to kind of sum this up in terms of what it is that’s going on and what potential patients can do to try to prevent any issue?
Chris: Yeah. Well, it’s a real issue. It’s a real problem. Babies are dying because of this. People are having massive heart attacks because of this. I honestly think people are too accepting when hospitals say, “Oh well, we have to consolidate services,” or “We have to cut costs.”
The Cleveland Clinic and University Hospitals aren’t struggling to make profits. When they come out with the highest-paid CEOs, the CEO of Cleveland Clinic and CEO of University Hospitals are always at the top of the list. And below them, there’s also whole layers and layers of management people that are making profits, and yet we’re taking services out of the communities where people, patients, are best served by getting care locally.
John: Yeah. It’s really putting them at risk.
Chris: Yeah. I mean, I wish I had the answers. I don’t, but I know it’s an issue. I think holding the hospitals accountable when mistakes happen, when babies die, when people die from heart attacks, because they didn’t get the care they needed, because it wasn’t at that hospital, and they were left sitting in that hospital…I think if you hold hospitals accountable for that, eventually they’ll get the message and bring services back.
John: All right. Well, that’s really great information, Chris. Thanks again for speaking with me today.
Chris: My pleasure, John.
John: And for more information, you can visit the Mellino Law Firm website at mellinolaw.com or call 440-333-3800.