MHA's Executive Briefing

AHA supports bill extending Section 1011

The American Hospital Association on July 29 expressed support for the Border Health Care Relief Act (H.R. 6394), which would provide $250 million annually through 2012 to help hospitals offset the costs of providing emergency care to undocumented immigrants. Sponsored by Rep. Gabrielle Giffords (D-AZ), the legislation would extend Section 1011 of the 2003 Medicare Modernization Act, set to expire Sept. 30 without congressional action.

According to a report by the United States-Mexico Border Counties Coalition, hospitals in border states provided more than $200 million in uncompensated care to undocumented immigrants in 2002. “Since that report was released, the problem has become even more serious because of the rising number of undocumented immigrants who continue to come to the U.S. and who require emergency health care services,” AHA wrote Giffords.

Under the Emergency Medical Treatment and Labor Act, hospitals must treat anyone who needs emergency care, regardless of their ability to pay and citizenship status.

[ via AHA News Now ]

EMTALA flexibility proposed to relieve on-call MD shortages

In a new Medicare hospital payment rule released in late April, CMS included a proposal clarifying its on-call policies under EMTALA. If finalized, the proposal would let a group of hospitals in a region designate one of them as the on-call site for a specific time period or service, rather than each struggling to keep up on-call coverage. For example, two hospitals could agree that for half of the month, one hospital would be the official on-call facility, while the other would serve that role for the second half.

In making such a proposal, CMS hopes to address the steadily worsening problem hospitals face with finding adequate on-call coverage by specialists. In 2005, the most recent year for which survey data was available, 73 percent of ED directors reported to the American College of Emergency Physicians that they were having trouble making on-call arrangements.

Regardless of what arrangements they made, individual hospitals with emergency departments would still be required to do a standard medical screening exam and have a plan for how to proceed if an on-call physician wasn't available. CMS wouldn't give preapproval to plans, but would review each plan if EMTALA violations arose after those plans were put in place. (The lack of pre-approval seems to me like a glaring problem--everyone wants a safe harbor determination in place when weighty federal violations may be in the offing-but we'll see, I suppose.)

To learn more about the EMTALA plan, read this AMNews article.

[ via Fierce Healthcare ]

CMS: "Parking" EMS Patients in Hospital May Violate EMTALA

In a July 13, 2006, letter to state survey agency directors (pdf), the Centers for Medicare & Medicaid Services (CMS) indicated that if a hospital prevents emergency medical services (EMS) staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, it may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA). CMS says it has received reports of patients being left on stretchers for extended periods of time with EMS personnel in attendance. CMS says that while it recognizes the enormous strain and crowding many hospital emergency departments face every day, the practice of "parking" patients is not a solution, as it impedes the ability of EMS personnel to provide emergency services to the rest of the community.

Calling for backup

As the emergency room has become the primary-care provider for millions of uninsured and underinsured Americans, on-call coverage has become an increasingly contentious issue between hospitals and their admitting physicians. At most hospitals it's still standard protocol to serve time on-call in the ER in exchange for medical staff privileges. But tradition may be on its way out as many specialists now consider call coverage to be a legal and financial risk that's not worth taking. Under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which aimed to prevent hospitals from turning away patients who are unable to pay, Medicare-participating hospitals with an ER must maintain an on-call list of participating physicians. But a technicality within EMTALA specifies that while hospitals are required to provide services, physicians are not. The oversight may be slight, but it's significant.

Read the full article from HealthLeaders Magazine.

AHA to CMS: Community hospitals struggling to provide on-call coverage

Uncompensated care, medical liability fears, changes in the lifestyle expectations of physicians, and physician-owned limited-service hospitals are making it increasingly difficult for community hospitals to meet their Emergency Medical Treatment and Labor Act obligation to maintain on-call emergency department coverage, AHA Senior Washington Counsel Maureen Mudron told a federal advisory panel on June 15. Since EMTALA does not create a mandate for physicians to serve on-call, it is unfair for the Centers for Medicare & Medicaid Services to "micromanage" the provision of on-call services in hospitals, said Mudron, addressing the EMTALA Technical Advisory Group. Unless physicians are required to serve on-call, CMS should find that hospitals have met their on-call obligations when they have acted in good faith to provide on-call coverage within the resources available, she said. Mudron added that physician-owned limited-service hospitals are exacerbating hospitals' struggle to maintain on-call specialty coverage, and that congressional action to prohibit physicians from referring patients to the specialty hospitals they own is vital to protecting community access to emergency care. (via AHA News)

Lower court's ruling reversed on scope of EMTALA

On March 23, a federal appeals court overruled a lower court decision that the Emergency Medical Treatment and Labor Act (EMTALA) covers diagnostic and treatment centers.

In Rodriguez v. American International Insurance Company of Puerto Rico, the U.S. Court of Appeals for the First Circuit rejected the district court's determination that it would be "unconscionable" not to extend EMTALA to cover the diagnostic center, Centro de Diagnostico y Tratamiento (CDT), with 24-hour emergency services because doing so would have the effect of "excluding the poor population who primarily rely on CDT services.

The appeals court disagreed with the district court in its conclusion that the spirit, if not the law, of EMTALA was meant to cover the action against CDT and its insurer, American International Insurance Company of Puerto Rico. In her decision, Judge Sandra L. Lynch wrote that, "Federal courts are not free to ignore the letter of the law in favor of the 'spirit' of a law. There is no legal ambiguity about the language Congress used in EMTALA - EMTALA requires the emergency room be of a participating hospital." (via Medical Staff Leader Connection, a HCPro.com publication)

AHA submits recommendations to new EMTALA advisory group

The AHA on March 30 recommended the Centers for Medicare & Medicaid Services review its authority to address physician on-call responsibilities and examine options to address the reasons physicians limit their on-call coverage. In a statement to a new CMS advisory group that will review regulations affecting hospital and physician responsibilities under the Emergency Medical Treatment and Labor Act, AHA said hospitals are in an “increasingly untenable position” because the act requires them to ensure on-call coverage by specialists yet the physicians have no obligation to serve on call, a situation exacerbated by the emergence of physician-owned limited-service providers. AHA recommended CMS also establish an appeals process for hospitals deemed noncompliant with EMTALA by a CMS regional office, and that the CMS offices not evaluate EMTALA compliance in a vacuum, but consider state and other regulations hospitals must meet in caring for patients, particularly psychiatric patients. (via AHA News Now)

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