[Paleopsych] ACP-ASIM Observer: Emergency access is mandated-but without money
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Thu Apr 14 14:05:12 UTC 2005
ACP-ASIM Observer, November 2001 - Emergency access is mandated-but
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
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
"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
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
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."
Emergency Medical Treatment and Active Labor Act links and resources
Breaking the law: Unresponsive on-call physicians
Hospitals in nearly every state violate federal patient dumping
law, study shows
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