EMTALA woes spark quest for national fix

Expansion of the "anti-dumping law" is driving Arizona physicians away from emergency care.

By Markian Hawryluk, amednews staff. Feb. 11, 2002.

The unintended consequences of emergency department regulations designed to prevent inappropriate patient transfers have created an emerging crisis in Arizona and are spurring its elected officials to look for ways to fix the problem nationwide.

The Emergency Medical Treatment and Active Labor Act was passed by Congress in 1985 to ensure that patients in need of emergency care were not turned away for inability to pay. But the regulations now pull physicians away from their practices to provide uncompensated emergency care, physician groups say.

As a result, frustrated specialists are increasingly refusing to be on the on-call list for emergency cases. And hospital emergency departments are facing overcrowding, budget shortfalls, and in some cases, closures.

"We have a disaster in medicine today," said Michael Carius, MD, president of the American College of Emergency Physicians. "Emergency medicine, unfortunately, is at the forefront of that."

Regulatory reform bills in Congress would only begin to address EMTALA concerns. A bill passed by the House would create an EMTALA task force to review the regulations and suggest possible solutions. Meanwhile, the Senate is considering legislation that would require managed care plans to make emergency care coverage decisions based on presenting symptoms, not the final diagnosis.

Members of the Arizona delegation to Congress are working with officials from the Centers for Medicare & Medicaid Services to explore administrative solutions to the problems. Sen. Jon Kyl (R, Ariz.) has made EMTALA a legislative priority this year.

Arizona's EMTALA problems are particularly severe due to a shortage of physicians, a large population of immigrants who lack adequate health coverage, and a high managed care penetration rate.

EMTALA regulations require that hospitals establish on-call schedules to ensure specialists are available 24 hours a day for emergency cases. That can be exceedingly difficult in rural facilities, such as the 250-bed Yuma Regional Medical Center in Yuma, Ariz., where Lee Hieb, MD, is an orthopedic surgeon.

There aren't always enough specialists in the area to establish a reasonable on-call schedule, Dr. Hieb said. And EMTALA is contributing to an exodus of physicians from university and trauma centers in favor of smaller hospitals that see less trauma.

"Several of our doctors who have just opted out of all care at the hospital to be outpatient practitioners have noted an increase in their income," Dr. Hieb said.

Many physicians believe that's not what Congress intended when it passed the "anti-dumping law."

"I think everyone agrees that the intention of the law is good. It's the way it was interpreted that's causing major problems," said Andrea Smiley, spokeswoman for the Arizona Medical Assn. "The interpretation needs to be looked at quickly and improved, especially in terms of how physicians and hospitals handle the on-call schedule."

The AMA believes CMS has expanded EMTALA well beyond Congress' original intent and increased physicians' potential liability. Congress intended the rules to apply to hospital EDs, the AMA said, not to hospital-owned physician practices, which may not have the facilities or personnel to treat emergency cases.

"What was once a five-page law is now a 25-page code of regulations with 100 pages of interpretive guidelines," AMA President Richard F. Corlin said in a speech to ACEP. "It's impossible for any emergency room to comply with all the regulations."

The AMA has called together an EMTALA task force, including nine major specialty societies, that will push for a return to the original congressional intent of the regulation and for reasonable payment for screenings and stabilization services.

Health and Human Services Secretary Tommy Thompson said last year that the department would undertake a thorough review of EMTALA regulations, but neither he nor CMS have proposed any refinements. CMS Administrator Tom Scully met with Arizona physicians in January to learn more about EMTALA problems. Scully said he intends to assemble a task force to look at some of these issues.

But there is concern that EMTALA problems may get worse this year. Many believe the 5.4% cut in Medicare payments may mean more referrals to EDs as doctors realize they cannot afford to treat complex cases in an outpatient setting.