Hospital Admitting Privilege Mandates Undermine Physician Practice and Unduly Burden Women's Access to Abortion

The American College of Obstetricians and Gynecologists is committed to ensuring access to the full spectrum of evidence-based quality reproductive health care, including abortion. Abortion is one of the safest medical procedures performed in the United States—safer than other routine medical procedures and substantially safer than childbirth. Yet, it is increasingly out of reach because of mounting government-imposed restrictions targeting women, physicians, and other clinicians.  

Mandates that abortion providers obtain hospital admitting privileges are one example of government restrictions that are not based in science, improperly regulate medical practice, and impede patients’ access to quality, evidence-based care. 

The admitting-privilege model is unnecessary for continuity of care 

• Admitting privileges are formal agreements between a physician and a specific hospital allowing the physician to directly admit patients to the hospital and provide services to their patients in that hospital as medical staff.  
• In modern medical practice, it is no longer the case that the same clinician necessarily provides both outpatient and hospital-based care.  In many specialties, including obstetrics & gynecology, some clinicians work exclusively in the outpatient setting and others work exclusively in the hospital.
• In these cases, effective planning and emergency protocols, including direct communication and collaboration between specialized healthcare providers, ensure prompt treatment and continuity of care—not admitting privileges.  
• Further the Emergency Medical Treatment and Active Labor Act, enacted in 1986, requires emergency departments to stabilize and treat any patients, meaning that patients receive emergency care irrespective of their physician’s privileges with a hospital.
• In 2019, the Centers for Medicare & Medicaid Services removed its requirement that ambulatory surgical centers participating in Medicaid and Medicare have hospital admitting privileges, asserting they were unnecessary in the promotion of patient health, an inefficient use of health care dollars, and an administrative barrier to efficient operations. 

Gaining admitting privileges is not tied to patient care and is unrelated to a clinician’s competence

• Clinicians can be denied admitting privileges for any reason; for example, because they do not reside in a specific locale or hold a faculty appointment with the hospital.  
• Some hospitals grant admitting privileges only if a physician agrees to admit a minimum quota of patients per year.  This patient quota may be impossible for a physician or clinician providing abortion to meet, because it is extremely rare that abortion will result in complications that require hospital admission. 
• Processes for approval of admitting privileges can take a lengthy amount of time and present significant bureaucratic hurdles and administrative burden to clinicians.
• Physicians who provide abortion care are routinely denied admitting privileges due to anti-abortion ideology, stigma, and fear of harassment.

Hospital proximity requirements compound already unworkable admitting privilege mandates

• Some admitting privilege mandates targeting abortion providers also require that they be at a hospital located within a certain number of miles from the clinic at which the physician provides abortions. 
• In the rare cases where a patient seeks hospital care after accessing abortion care, they are more likely to do so after returning home from the clinic, potentially far away from the hospital at which their clinician was mandated to have admitting privileges.
• A physician may have active admitting privileges, but not within the required radius. Hospital-proximity mandates are especially problematic in states with rural areas where hospitals are scarce.

Admitting privilege mandates are not accepted by the medical, legal, or research community 

•  The National Academies of Sciences, Engineering, and Medicine, in reviewing the state of science on all methods of abortion found that the greatest threats to the quality of abortion care in the United States are unnecessary and burdensome government regulations. The report explicitly states that it found “no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient.” 
• ACOG, along with colleague organizations across the women’s health and primary care fields, led a rigorous review of the available evidence and guidelines that inform safe delivery of outpatient care.  In the published findings, the authors note that in policy and law, regulation of abortion is frequently treated differently from other health services and that false concerns for patient safety are being used as a justification for promoting regulations that specifically target abortion. 
• Thirteen major medical organizations, including the American Medical Association, joined ACOG in opposing a Louisiana admitting privilege mandate as an undue burden to abortion care. 

In 2016, the US Supreme Court struck down a state admitting privilege mandate, holding that it did not protect women’s safety and did create an unconstitutional and undue burden on access to abortion. The Court relied on medical experts, including ACOG in concluding that common prerequisites for admitting privileges “have nothing to do with the ability to perform medical procedures.” 

ACOG welcomes working with government officials and safety experts on ways to ensure our patients receive safe, high quality care. There is no medical, legal, or safety justification for admitting privilege mandates; rather, they undermine physicians’ ability to practice the full scope of obstetrics and gynecology and impose additional, sometimes insurmountable, barriers to abortion access.

References

1. National Academies of Sciences, Engineering, Medicine, The Safety and Quality of Abortion Care in the United States (March 2018); see also Raymond & Grimes, The Comparative Safety of Legal Induced Abortion and Childbirth in the United States, 119 Obstetrics & Gynecology 215, 216 (2012).
2. Increasing access to abortion. Committee Opinion No. 613. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:1060—5.
3. 42 U.S.C. §1395; 84 Fed. Reg. at 51738
4. National Academies of Sciences, Engineering, and Medicine. The Safety and Quality of Abortion Care in the United States (March 2018) at https://www.nap.edu/read/24950/chapter/1
5. National Academies of Sciences, Engineering, and Medicine. The Safety and Quality of Abortion Care in the United States (March 2018) at https://www.nap.edu/read/24950/chapter/1
6. ibid
7. Report from the project on facility guidelines for the safe performance of primary care and gynecology procedures in offices and clinics. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:255–60.
8. Barbara S Levy et al., Consensus Guidelines for Facilities Performing Outpatient Procedures; Evidence Over Ideology, 133 Obstetrics & Gynecology 255, 258 (2019)
9. Brief for the American College of Obstetricians and Gynecologists as Amicus Curiae, June Medical Services, L.L.C. v. Gee Nos. 18-1323 & 18-1460 (2019). (Medical organizations joining ACOG on the brief are the American Medical Association, the American Academy of Family Physicians, the American Academy of Nursing, the American Academy of Pediatrics, the American College of Nurse Midwives, the American College of Osteopathic Obstetricians and Gynecologists, the American College of Physicians, the American Osteopathic Association, the American Public Health Association, the American Society for Reproductive Medicine, the North American Society for Pediatric and Adolescent Gynecology, the Society for Maternal–Fetal Medicine, and the Society of OB/GYN Hospitalists.) Whole Woman's Health v. Hellerstedt, 136 S. Ct. 2292, 2299 (2016).