The regionalization of care poses problems for even the best-insured patients. A regional facility, with its complement of subspecialist practitioners, has a substantial stake in keeping specialty beds full. This situation can lead to overinclusive policies on the necessity for specialty care. Neonatologists in some centers, for example, establish standards of care that require pediatricians to refer as many infants as possible to the neonatologists for care. A failure to make these referrals could be malpractice by a pediatrician. The pediatrician, however, does not have the power to force acceptance of a particular patient. If the regional care system is full, the problem of finding a place for a severely premature infant falls to the pediatrician because there is no duty for the neonatologists to transfer less-ill infants to make room for more- ill patients.

A physician with a patient who needs special care must pursue all options until a place is found for that patient. In some celebrated cases involving indigent, premature infants, this has required searching in several states and calling on the military for emergency transport. The physician’s best allies in such situations are a newspaper reporter and a public interest attorney. The threat of adverse publicity and litigation can work wonders in finding care for an individual patient.

If rejections happen too frequently, community physicians should work with the regional centers to correct the problem. Specific guidelines should be established that specify which patients have priority for the space available and which patients will be moved or discharged first when a higher- priority patient comes in. It is hard to defend keeping a terminal cancer patient in the only intensive care bed available if it means that a patient with a heart attack may die for lack of care. Physicians who practice in communities that do not provide adequate indigent or specialty medical care services must warn their patients that they may be denied necessary care. Physicians in these areas also should assist patients in using the federal and state laws to gain access to medical care.