Can we turn away pt's from the ER now?

[jawurheemd]

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Just FYI. I don't think this is a good thing by the way.

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Emergency Room Requirements Eased



By Maggie Fox, Health and Science Correspondent

WASHINGTON (Reuters) Sept 03 - The Bush administration said on Wednesday it was easing rules that require hospitals to provide emergency care to anyone who seeks it.

The revisions, sought by the hospital industry, reduce a hospital's liability for treating emergency patients and would make it easier for a facility to turn away patients.

More than 40 million Americans lack health insurance, and many of these uninsured use emergency facilities. Emergency room staff say they often cannot handle the influx and cannot provide proper care.

The changes, which take effect in November and require no congressional approval, affect the 1986 Emergency Medical Treatment and Labor Act (EMTALA).

This measure requires any hospital taking part in Medicare--the federal health care insurance program for the elderly and the disabled--to provide "appropriate medical screening" to anyone showing up for treatment at an emergency room.

On pain of a $50,000 fine and suspension from Medicare, the hospitals must also stabilize the patient or transfer the patient to a clinic or hospital that can do so.

Hospitals say the rules have burdened their emergency departments with poor and uninsured patients seeking care for everyday conditions. Many have closed emergency facilities in recent years.

The change eases some of the restrictions, said the Centers for Medicare & Medicaid Services (CMS), a branch of the Health and Human Services Department that is responsible for the rule.

"The regulation we are announcing today carries out EMTALA in a common-sense and effective way to ensure that people who come to hospitals seeking emergency care are promptly screened and stabilized," CMS Administrator Tom Scully said in a statement.

"The rule will improve people's access to emergency care by encouraging physicians to be on call and by permitting hospitals to take the most effective steps for getting emergency treatment for patients who need it."

For instance, the rule will allow hospitals more flexibility in keeping doctors on call.

"In keeping with traditional practices of 'community call,' physicians will be permitted to be on call simultaneously at more than one hospital, and to schedule elective surgery or other medical procedures during on-call times," said CMS.

It will also allow ambulances to take patients to a variety of hospitals or clinics.

"One example is an ambulance owned by a hospital," White House spokesman Scott McClellan told reporters. "The regulations would no longer require that ambulance to return to that hospital if there is a closer emergency room that that ambulance could go to."


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[DrQuinn]

I read that article previously, and a separate article about the same topic... and essentially the EMTALA laws are the same (as they should be), however, recently the regulations have been strictly enforced, especially in regards to which physicians need to be on call and how they can be on call (i.e. more than one hospital at a time now)... that's what's changed, not the core of the EMTALA law (which is a good thing).

Q, DO

 

[ERMudPhud]

My take after reading about the changes and reading the summary published by the government was that we would see two main changes The first was that non ER's (clinics, dialysis centers, urgent care centers) affiliated with institutions which have ER's would no longer be held to the EMTALA standards. Attorneys were suing non-ER's for violations of EMTALA because the fear of an EMTALA violation pushed people to settle and because EMTALA violations weren't limited by the tort reform in some states thus allowing for more lucrative settlements. The other more detrimental change is in the rules on consultant staffing. Under the old rules hospitals were supposed to provide 24/7 coverage for any specialty that normally practiced in their hospital. In other words if a patient with a severe hand injury, say an actively bleeding ulnar and radial artery, came in the middle of the night and your hospital had hand surgeons on staff than someone had to be on call to take the patient emergently to the OR. The new rules allow consultant to cover more than one hospital which is a good thing but they are very vague on how much coverage hospitals are required to provide. The net effect is that it appears hospitals will be able to say, "sorry, we will only provide hand coverage mon, wed, and fri from 9-5" If you present outside that time you will have to be transferred somewhere else assuming you can find any other hospital willing to take an uninsured patient in transfer in the middle of the night. We are already seeing many surgical subspecialist who do most or all of their work at outpatient surgery centers (ophtho, plastics, hand, etc...) refusing to take call thus leaving us with no backup for the problems beyond our scope of practice. Without the threat of EMTALA this problem may become worse. Last week I saw a kid with a big piece of glass sticking through his cornea. I could forsee the day when I'll have to tell his parents, "sorry, can you come back tomorrow I can't find an ophthalmologist" you can substitute devascularized hand injuries or any of a host of other devastating injuries for the above. The net effect will be an increase in usage of county and academic centers where there will always be a specialist on call even if it is just the intern covering that service.

 

[ERMudPhud]

If you want to read the government summary it can be found here

http://www.cms.gov/media/press/release.asp?Counter=837


a relevant quote:

Clarification of the circumstances in which physicians, particularly specialty physicians, must serve on hospital medical staff "on-call" lists. Under the revised regulations, hospitals will have discretion to develop their on-call lists in a way that best meets the needs of their communities. In keeping with traditional practices of "community call," physicians will be permitted to be on call simultaneously at more than one hospital, and to schedule elective surgery or other medical procedures during on-call times.

In other words, a hospital could say that 3 days a week of hand call best meets the needs of our community and be done with it.

 

[EMRaiden]

No ... we still have to see everyone who presents and perform "an appropriate screening exam" as far as I understand... from there we're screwed because now our recourse is limited and the call requirements have been softened a little. (EMTALA was like an invisible goon you could invoke when calling a consultant.. even the most arrogant, pain in the ass plastic surgeon doesn't want to pay $50k out of pocket).

 

[jawurheemd]

So basically we do everything ourselves because no one is going to be on call. I guess we'll be doing ER appys and craniotomies soon.

 

[Sessamoid]

The clarification recently issued doesn't really change much for us. It does change what's considered allowable for on-call schedules and on-call surgeons. As noted, also big changes for other non-ED settings as well, which also don't affect us.

EMTALA always runs up against the problem that you can't legislate physicians to be on-call when there aren't any around. There is a relative scarcity of many subspecialties in large geographic areas of the country. Forcing hospitals to have 24 hour coverage for specialties in which they only have one surgeon isn't going to help that hospital get coverage. It's going to convince that last surgeon in that specialty to no longer hold privileges at that hospital, a situation that is to no one's advantage. Allowing surgeons to take call at more than one facility is simply the only practical solution, and the recent statement only recognized that fact.

 

[ERMudPhud]

I am afraid the net result for us will be somewhat worse. I work in an urban setting and we have no shortage of subspecialist. We have at least half a dozen hand and plastic surgeon on staff, more than a dozen ophthalmologists, and even more orthopods but we still have had trouble getting them to agree to take call. Now that EMTALA has acknowledged that 24/7 may be impractical in some setting I am afraid people will use this to claim it is impractical in our setting which isn't true

 

[Sessamoid]

Originally posted by ERMudPhud
I am afraid the net result for us will be somewhat worse.

I'm sure some will try to use that excuse, but it sounds like your medical staff committee would have to be seriously deluded to think that CMS would accept anything less than a fully-stocked call schedule at your hospital if they were investigated. I do know of several hospitals in the area that have been unable to get specialty coverage at all because of the previous vagueness in the requirements. The new vagueness makes it easier for them to get at least somebody on-call part of the time.

 

[ERMudPhud]

Originally posted by Sessamoid
I'm sure some will try to use that excuse, but it sounds like your medical staff committee would have to be seriously deluded to think that CMS would accept anything less than a fully-stocked call schedule at your hospital if they were investigated.

Already within the last year and without the new vagueness. Ophtho and trauma surgery succesfully lobbied to get paid by the hospital for being on call. Of course with that precedent now everyone else wants the same deal. As of last week we no longer had 24/7 hand or plastics and the plastics guys that are left are refusing to take hand calls. Our main ortho group self destructed partly over the issue of call and splintered into a bunch of single practitioners. The sports and hand guys stopped taking call altogether leaving the joint replacement and spine guys who still can't do all their stuff at ambulatory centers and thus still need the hospital to take all the call. I'm sure its only a matter of time before ENT, OMFS, and others go the same way. I hear things are actually worse in other parts of the country and we have it pretty good. I've heard of hospitals where consultants blatantly and openly refuse their EMTALA obligations.

 

[Sessamoid]

Originally posted by ERMudPhud
Already within the last year and without the new vagueness.
....
I've heard of hospitals where consultants blatantly and openly refuse their EMTALA obligations.

Holy sheep turds. I've still got 24/7 coverage in everything but GI and that's only because of some non-emtala related hospital politicking. I feel for you man. Thankfully, even in GI I have a few docs who are willing to come in even in the middle of the night for unfunded patients just because it's the right thing to do. Those are the same guys I refer all my funded patients to.

I guess it's going to take a $50K lesson for medical staff committees like your to learn the lesson. Or at least some $50K lessons in the community.

You mentioned surgeons being paid to take call. That's hardly a new thing in certain subspecialties. I have a cousin who was offered more than I make in a year just to take oral surgery call at a major metropolitan hospital, and this was at least 5 years ago. I thought he was stupid for not taking the job, even though it would have required relocating his family.

 

[docB]

The attitude of most consultants, particularly surgical consultants, is that they don't have any EMTALA obligations. They consider EMTALA to be a hospital and ER problem and they couldn't care less what happens to the ER. They still like to refer their after hours (or 4pm on Friday) patients to the ED tho...

 

[ERMudPhud]

Originally posted by Sessamoid
Holy sheep turds. I've still got 24/7 coverage in everything but GI and that's only because of some non-emtala related hospital politicking.

Actually I've got great coverage for GI (and most medical subs for that matter). I'll trade you a gastroenterologist for a hand surgeon. As for the paying to take call the problem now is that EVERYONE wants it. Not just the surgical subs but even the family practice or medicine doc on call for unassigned patients, even the ICU docs who were typically in house when on call anyway

 

[SHOX]

I think we can all agree that the intent of EMTALA was a good one. However the fact that it is an unfunded mandate has produced an onerous burden on EDs. I think we can also agree that government has some responsibility in funding care for its 40+ million uninsured. The national and state governments have shifted their responsibilities to the ED. In addition to EMTALA, Medicare funding for hospitals and physicians has declined. As the number of hospitals/EDs diminish, the volumes of existing EDs increases. Our EDs are crowded and as a result more inefficient. Although most EDs provide great care... it is expensive care and not primary care. In the end the patients suffer... ED funding diminishes... further straying the one safety net left in our nation's health care system. This was yet another good idea the government takes and completely manages to screw up... case in point: HIPPA!

SH

Now, I will get off my soap box! 😉

 

[Coleman]

Although most EDs provide great care... it is expensive care and not primary care. In the end the patients suffer... ED funding diminishes... further straying the one safety net left in our nation's health care system.

Shox has made a great point. EMTALA which I will not argue is necessary in its inception and currently, was created to deal with critical/emergent cases. What it has evolved into is forcing primary care of the uninsured. The government is not forcing FPs and IM clinics to see unfunded pts, so they are coming to us and bringing their kids along for checkups. If the money spent on the "emergency primary care" for the uninsured was spent on actual primary care, you could take care of 9-10 patients for every 1 in the ED.

A little side bar, while the plight of the uninsured is not lost on me, I find it odd that many refer to this "population" as a united front of hard-working Americans who are just down on their luck. This is not always the case, as many have jobs, money, family, and do not have insurance because it is too expensive for their tastes. I spoke with one man who said he could not come back tomorrow because he had to get his car fixed. So, he'll pay to have his oil changed and car repaired, but he expects free medications and doctors visits. . . .

interesting . . .

 

[Febrifuge]

I think Coleman has illustrated another really important point about why this issue is so thorny...

I spoke with one man who said he could not come back tomorrow because he had to get his car fixed. So, he'll pay to have his oil changed and car repaired, but he expects free medications and doctors visits. . . .

This can be the toughest part to talk about, because those who don't believe the safety net should be so large or cost so much have ready examples of this kind of exploitation of the system. Meanwhile, bleeding-heart Liberals like myself hate to start acknowledging that there is abuse of the system, as though that would be showing weakness or starting down a slippery slope.

But there is abuse. I see it every time I work a shift in my metro area's safety-net hospital ED. I'm proud to work for the place the uninsured know they can't be turned away, but our good intentions have, at times, been taken for granted. A doc I shadowed for a day (whose politics are about 180 degrees away from mine) said something I took to heart: "solving the healthcare problem is going to have to involve a certain amount of saying no." I happen to believe some of that will need to be a very specific and limited ability of the system to turn people away, but it will also need to be a higher degree of responsibility on the part of the government to pay up.

In other words, we could use some "you want to be seen for your mosquito bites? No." And we could also use some "you want to legislate this but give us no money to do it? No."

I don't think we'll be able to make great strides until we take some baby steps. Over on the Conservative end, it would be good to see both houses of Congress acknowledging the reality and the unfairness of the unfunded mandate that's been described above. Along with that should be some admission that the federal and state governments have left hospitals to twist in the wind. Maybe this change is at least some sort of a prelude to a better discussion. Then again, I'm a starry-eyed optimist...

 

[docB]

EMTALA is really just a symptom of the larger problem. Not that the gubmit didn't screw us, they did. But it's still just a symptom. I'll guarantee that I'm the most conservative guy on this board. My ideal plan for this problem is that we have triage that boils down to productive member of society or not. If not yoyomf and that's that. Clearly that's not going to happen. I am completely, ideologically opposed to socialized care but at this point I am pragmatically ambivalent to it. In other words my feeling now is that they can go ahead and socialize, cut my salary and give me a medical cook book to follow that doesn't include any patented drugs. I say this because once I become a federal employee just try to sue me. Maybe we could even get union rules. "So you want to rape me for a legally sanctioned jackpot. Well you and your shyster will have to start with the Surgeon General and the US Dept. of Health, HHS and various other layers of bureaucracy. Oh, and I only work 40 hrs a week so you can wait in line."