EMTALA flexibility proposed to relieve on-call MD shortages

Wed, 11 Jun 2008 06:59:58 -0400

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

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Patient dumping issues need systematic look

Fri, 16 May 2008 06:59:59 -0400

At this point, you've heard frequently about the problem Los Angeles faces with "patient dumping," which takes place when hospitals discharge indigent patients and more or less kick them to the curb.

Allegedly, several LA hospitals with otherwise decent reputations have engaged in this practice. Some have been caught leaving mentally-handicapped or severely ill patients to wander around the city's infamous Skid Row in the hopes somebody else--probably, the homeless mission there--would deal with the patient's problems from that point on.

Now, I've taken a potshot or two at LA's hospitals, but in reality, I'm betting they don't dump patients any more often than hospitals in any other big cities. Sadly, I've little doubt that homeless patients get discharged and kicked out of vans and taxis onto rough streets in New York, Dallas and Miami, too.

The thing is, just how widespread is this practice? I wish I could tell you. While I wanted to share statistics that would give us a better overview of the problem, I didn't find any. The best I could come up with in my web research was a report released by Public Citizen in 2001. Public Citizen's data, which consisted only of EMTALA violations taking place between 1997 and 1999, noted that violations had been confirmed for 527 hospitals in 46 states during that period.

However, if that many EMTALA violations are being confirmed, one can only imagine that the kind of patient dumping we've described is even more common. After all, to commit an EMTALA violation, it has to happen in your emergency department, and it probably was documented in some form. Dumping a poor, homeless, mentally-ill patient and sticking a homeless shelter with their care may barely show up.

All told, it seems to me that this class of patient dumping needs far more study, and once the subject is better understood, the industry needs to take aggressive steps to address the problem before it happens. While I commend the LA city attorney's office for attempting to solve the problem by censuring offenders, it's our job as industry participants to see if we can fix what's broke. Readers, do you have any thoughts on this (or relevant research to share)? I'd love to hear from you. - Anne