[Paleopsych] ACP-ASIM Observer: Emergency access is mandated-but without money

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ACP-ASIM Observer, November 2001 - Emergency access is mandated-but
without money
American College of Physicians-American Society of Internal Medicine.
[Note the date.]

    While legislation requires hospitals to provide basic access to
    emergency care, physicians say that the law lacks one critical
    element: any source of funding to pay for the care they must provide.
    That omission, they say, is helping drive physicians away from taking
    ER call.

    Federal legislators passed the Emergency Medical Treatment and Active
    Labor Act (EMTALA) in 1986 in the wake of the newly implemented
    diagnosis related groups (DRG) reimbursement system. As hospitals
    realized that DRGs would eliminate funding that had allowed them to
    subsidize uncompensated care, some began refusing to give emergency
    treatment to indigent or uninsured patients or started "dumping" them
    on public facilities. The new law theoretically put an end to such

    Under EMTALA, emergency departments must screen all comers. They must
    treat a patient's condition until it is stable, or arrange a transfer
    to a facility that can, regardless of the patient's ability to pay. A
    hospital must also accept transferred patients if it can provide the
    specialized treatment patients need. And hospitals must maintain a
    list of on-call physicians who are available to treat emergency

    The act also requires hospital bylaws to define the responsibilities
    of on-call physicians and implement policies to guide emergency
    workers when a specialist is not available or when an on-call
    physician is not able to respond. Physicians providing emergency
    care--including those on call--who violate any part of the law are
    subject to a $50,000 fine and can be excluded from Medicare.

    Critics say that the act is flawed on several fronts, however. First,
    they complain, it does not reimburse hospitals or physicians for this
    mandatory coverage.

    "The cost of maintaining emergency services has never been accounted
    for in the American health care system," said Loren A. Johnson, MD,
    medical director at Sutter Davis Hospital in Davis, Calif., and
    president of the California chapter of the American College of
    Emergency Physicians. "It's all based on goodwill, and the care
    hospitals and physicians provide out of a sense of social contract and
    civic duty."

    Physician groups such as the American College of Emergency Physicians
    are advocating for funds to pay for the universal EMTALA mandate.
    Among other solutions, they recommend restructuring Medicare's
    inpatient disproportionate share funding.

    Critics also say that the law holds hospitals, not doctors,
    responsible for ensuring on-call coverage. In some cases, for
    instance, on-call specialists have refused to allow patients who
    needed their specialty services to be transferred to their hospital.
    The hospital was fined for violating the law, not the physicians.

    "The construct of the law places the direct risk and responsibility on
    the hospital, and indirect responsibility on the medical staff," Dr.
    Johnson said. "If medical staff refuses to take call and be on a
    roster, we lose the service but it never gets reported."

    Physicians don't get reported because emergency physicians do not rat
    out members of their own medical staff. Instead, they often "go
    vertical," Dr. Johnson said, calling their way up the chain of
    hospital administrators to find someone to lean on a specialist to

    As a result, few physicians get fined for EMTALA violations. According
    to a report issued by the General Accounting Office (GAO) earlier this
    year on the law's implementation and enforcement issues (see
    [29]http://www.gao.gov/daybook/010622.htm), less than 30 physicians
    have been cited for violations since the law was passed 15 years ago.
    The same report claimed that the Centers for Medicare and Medicaid
    Services (CMS), formerly HCFA, investigates about 400 EMTALA
    complaints against hospitals every year and cites about half of them.
    From 1995 to 2000, the report states, the OIG fined more than 190
    hospitals nationwide a total of $5.6 million for EMTALA violations.

    Given the growing attention to the problem of on call panels, however,
    the regulatory aspect of the law may go into higher gear. "I keep
    hearing from CMS that significantly more on-call citations are in the
    pipeline," Dr. Johnson said.

    But if that happens, the threat of running afoul of the law might
    further cut the number of physicians willing to take ER call. "Only
    those physicians who are doing their civic duty place themselves at
    risk," Dr. Johnson explained. "EMTALA may be a tool to enforce
    hospital and medical staff responsibility, but it is a perverse
    incentive for individual physicians to voluntarily take call."

[26]Emergency Medical Treatment and Active Labor Act links and resources
[27]Breaking the law: Unresponsive on-call physicians
[28]Hospitals in nearly every state violate federal patient dumping
    law, study shows


   26. http://www.acutecare.com/emtalalinks.htm
   27. http://www.msleader.com/articles/msb200p1.cfm
   28. http://www.citizen.org/pressroom/release.cfm?ID=170
   29. http://www.gao.gov/daybook/010622.htm

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