GOVERNMENTRegulatory reform panel targets EMTALA rulesDraft recommendations would limit the scope and modify definitions of the law prohibiting "patient dumping."By Markian Hawryluk, amednews staff. April 15, 2002. Washington -- About 15 years ago, Gary Dennis, MD, installed a shunt for a newborn with hydrocephalus -- not an unusual procedure for a neurosurgeon. But when the Washington, D.C.-based physician recently received a telephone call about the patient, he was stunned. The shunt had become obstructed and the girl, now a teenager, had lapsed into a coma. The hospital emergency department where she was being treated had no neurosurgeon on-call and wanted to transfer the patient to Dr. Dennis -- from West Virginia. Despite his protestations that the girl could die, the hospital sent her on a four-and-a-half-hour journey to the nation's capital. Thirteen hospitals were passed along the way. Under federal regulations, Dr. Dennis could not refuse the patient. Dr. Dennis is now a member of Health and Human Services Secretary Tommy Thompson's Advisory Committee on Regulatory Reform, charged with reducing the burdens of federal health care rules. One of the committee's first targets is the Emergency Medical Treatment and Active Labor Act -- the law that required Dr. Dennis to take that patient. Passed in 1986, EMTALA was intended to ensure emergency departments did not turn away critical cases because of the patient's inability to pay. But it is now criticized by some as a morass of regulations and guidelines that has health care lawyers working overtime. The law has been blamed for overcrowded emergency departments and a shortage of specialists willing to serve on hospital on-call lists. In March, the government reform panel released a set of draft recommendations aimed at reducing EMTALA's burden, and the group may vote to finalize them as early as May or June. The draft includes immediate fixes, such as simplifying the regulations and limiting their scope, and long-term solutions, such as creating a board of emergency physicians and other advisers that would guide future emergency department regulations and guidance. Once the panel makes its formal suggestions, it would then be up to HHS to accept or reject them.
Uncompensated care for illegal immigrants has strained both Tucson trauma centers.
The draft recommends that EMTALA rules apply in any given situation only until a decision is made that the patient does not require emergency care, should be admitted or should be transferred to receive the appropriate care. It would also limit the law's reach to the emergency department or any other hospital-owned facility that holds itself out to the public as being capable of providing emergency care. The panel would also like to see EMTALA preempted when hospitals are following community-based protocols for dealing with a disaster or incident of bioterrorism, or EMS plans, such as 911 protocols. The law would also not apply to patients who have been referred to the emergency department for diagnostic or scheduled therapeutic services, under the draft recommendations. For cases in which EMTALA violations are alleged, the draft calls for peer review organization reviews to occur earlier in the process and would require hospital notification once the investigation was completed. On-call not addressedPhysician groups have reserved comment until the committee finalizes its proposal. But one potential sore spot is that the recommendations do not provide much relief for on-call physicians. Under EMTALA, those physicians often must leave scheduled patients at their practices to attend to emergency department cases for which they are not compensated. Some physicians have refused to serve on-call, and many have severed ties with hospitals as a result of the law. Other physicians have dropped their credentials in all but their core specialty to avoid being called in for emergency department cases. Doctors "sometimes operate eight, 12, 15 hours a day. They have to be on-call the whole night. They're expected to come in and take care of problems, and then the next day they're expected to go back and perform with an office full of patients," said Carlos Lavernia, MD, chief of orthopedics at Cedars Medical Center in Miami. "We really need to clarify the expectations for responding to the on-call services." Other EMTALA issues pop upRecent hearings and reports serve to highlight some of the problems EMTALA has generated. In Arizona, a recent congressional field hearing on border control issues pointed out how EMTALA problems are magnified in that state and others, such as California and Texas, with large indigent and illegal immigrant populations. David Aguilar, chief patrol agent for the Tucson sector of the U.S. Border Patrol, told lawmakers that agents won't take into custody injured illegal immigrants in order to avoid assuming responsibility for their medical costs. Instead, agents often call local ambulance services, leaving the responding hospital to foot the bill.
The Border Patrol has only $1.5 million for health care of those in custody.
According to James Dickson, CEO of Copper Queen Community Hospital in Bisbee, Ariz., the increase in uncompensated care for illegal immigrants has led to closure announcements by both Tucson trauma centers. One was spared a shutdown only by an emergency bailout from the Arizona Legislature. "The INS Border Patrol has an internal policy not to apprehend these immigrants if they are in need of medical care," Dickson said. "This cost avoidance by the federal agencies and the state government leaves the strained health care system in Cochise County to absorb these costs." Part of the problem is the Border Patrol has only $1.5 million budgeted nationwide for the provision of health care services to individuals in their custody. In February, Rep. Jim Kolbe (R, Ariz.) introduced a bill that would establish a five-year pilot program to provide federal payment for hospital emergency medical care and ambulance services for illegal immigrants. EMTALA has also been blamed for adding to overcrowding woes in emergency departments. A new study published in the April Annals of Emergency Medicine found that in California the number of visits increased 27%, to an average of 25,778 visits per emergency department annually. While the study found that the number of nonurgent visits to emergency departments declined 8%, it noted that the drop might be a symptom of overcrowding. "If you pour water into a full glass, it simply overflows," said Robert W. Derlet, MD, an emergency physician with the University of California, Davis Medical Center in Sacramento. "In the case of emergency departments, when they are filled with very sick and injured patients, other patients, mostly nonurgent, leave after waiting what may be long periods of time in the waiting rooms." ADDITIONAL INFORMATION:Reining in EMTALAThe Dept. of Health and Human Services Regulatory Reform Committee's draft recommendations on EMTALA would:
Copyright 2002 American Medical Association. All rights reserved.
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