There’s suddenly a lot of conjecture flying about a patient who died in the University of Chicago’s emergency department a couple of months ago. Everyone that reads this blog had a heads up on the event way back on February 8.

According to news reports, a 78-year-old man was brought to the emergency room by ambulance about 12:30 PM. He was put into a wheelchair in the waiting room, but was neither triaged nor logged in. At 4:15 PM, the patient’s daughter wheeled the patient to the triage nurse to ask about the delay. The triage nurse noted that the man wasn’t breathing and called a code, even though rigor mortis had already set in. Unfortunately, rigor mortis is one of those things that usually precludes a successful cardiac resuscitation.

We don’t know anything about the man’s health or his complaints. All we know is that he was brought in by ambulance, sat in the waiting room for 4 hours (at least some of the time accompanied by his daughter), and was dead for a while (rigor mortis takes several hours to set in) before anyone noticed it. Be careful drawing conclusions without knowing all the information.

The University of Chicago admitted that procedure wasn’t followed. In other words, given the recent adverse publicity at the University of Chicago, a couple of nurses had to take the fall for what happened. The University of Chicago posted a statement about the incident emphasizing the U of C’s commitment to quality and safety.

Illinois State, the Medical Marijuana Advocates, and federal investigators are all looking into the incident. Some news reports stated that the feds have now cited the University of Chicago Hospital for an EMTALA violation.

Then comes the big stick. CMS allegedly sent the University of Chicago a letter threatening to take away the University of Chicago’s Medicare funding.

What an idle threat.

If I were the CEO at the University of Chicago, and the feds told me they were considering whether to revoke the hospital’s Medicare funding, I’d give them a double dog dare to go right ahead.

The Emergency Medical Treatment and Active Labor Act (“EMTALA” for short) only applies to “participating hospitals” – those hospitals that receive federal funding under Title 42 of the US Code. If the feds kick the University of Chicago out of the Medicare program and it no longer receives federal funding, then, just like free-standing emergency departments, the University of Chicago has no further duties under EMTALA. It wouldn’t have to provide a screening exam to patients. It wouldn’t have to provide stabilizing care to patients. If the patient doesn’t have insurance, the University of Chicago could essentially tell patients to “go to the county hospital.” It could even call an ambulance and have the ambulance transport the patient to another hospital. It could transfer patients to other hospitals without the transfer being “appropriate” under the EMTALA rules. EMTALA requires that hospitals accept transfer of patients if the hospital provides specialty services, so the receiving hospitals would be stuck taking any patients that University of Chicago decided to send them. Added bonus: the Joint Commission would no longer have any business in University of Chicago’s affairs.

A termination from the Medicare program could be a blessing in disguise. Without being subject to EMTALA, the University of Chicago could technically engage in “patient dumping” and only accept patients with insurance. True, a hospital would lose the income from Medicare (which is the dominant player in the market), but maybe that shift to providing only funded care would make up some of the difference because the hospital would no longer have to provide unfunded care or underfunded care. Would people with insurance go to University of Chicago preferentially if there was less crowding in the ED, if they were treated like royalty, and if appointments were easier to obtain? Might take some number crunching, but an entirely for-profit hospital might be sustainable – especially in a large city.

The thing is … if University of Chicago takes that gamble and is successful, how many other hospitals would consider whether or not to make the same leap? Would a successful large for-profit-only hospital system be the first step to creating a “two level system” where the best doctors go to entirely privately funded hospitals because they receive more compensation, but those doctors aren’t available to patients without a means to pay? Would all patients on public funding then get sheep herded into the public hospitals where they get free care that might not be as high quality or as accessible as at the for-profit hospitals?

Or maybe the University of Chicago will be so affected by the lack of federal funding that it will go out of business like so many other Illinois hospitals.

In either case, remember all those patients that were having difficulty obtaining emergency medical care? Remember Dontae Adams whose face was “chewed off” by a pit bull? Close the University of Chicago or turn it into a strictly for-profit institution that is not subject to EMTALA and guess what happens to all the patients who have public funding or no insurance at all? NONE of them get any care at the University of Chicago. They all get sent to other hospitals that are still required to provide EMTALA-mandated care.

With the new onslaught of low paying patients, wait times at surrounding hospitals will increase and quality of care will inevitably decrease. Eventually, the volumes of patients will overwhelm the surrounding hospitals’ resources to the point that patients will die in other emergency department waiting rooms. More CMS investigations. More hospitals will close.

Lather. Rinse. Repeat.

Less hospitals, more patients in the emergency departments. Yeah. That will go over real well.

So CMS, if you’re playing a game of “chicken” with University of Chicago, you better be driving something larger than a Cooper Mini.

I’ve got another idea: How about fixing the funding of emergency care in this country before waiting room deaths become an everyday occurrence?

Like this.
Or this.
Or this.
Or this.
Or this.
Or this.

Fast care, free care, quality care. Pick any two.

As Scalpel once said, sometimes you only get to pick one. “Free” doesn’t always cut it.

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Also see related articles at:
Huffington Post – University Of Chicago Hospital May Lose Medicare Certification After ER Death
Chicago Sun-Times – U. of C. admits problems with ER death
WBBM Chicago Radio – Feds Threaten Action Against U of C Med Center

The bad blood between the Chicago Tribune and the University of Chicago continues. While most sources had one article about the incident, the Chicago Tribune has had three (and will probably have about a half dozen more):

U. of C. Medical Center says ‘protocol’ not followed in ER death
Medicare warns U of C Medical Center after ER death
University of Chicago Medical Center in violation of emergency room services law, U.S. alleges

UPDATE MARCH 30, 2009

Leave it to Shadowfax to set me straight. See his post related to the above here.

I didn’t consider the funding that training programs receive from the federal government in my equation and agree that removal of such funding would be a death knell for the training program and, more likely than not, the affiliated teaching hospital.

Shadowfax and I are looking at the same problem from two different angles, though.

Shadowfax’s post brings forth some criticisms about the University of Chicago using factual allegations to which I’m not privy.

I’m looking at the issue more from the angle of what happens when a bully picks on too many nerdy kids or what happens when you back an animal into a corner. Right now, hospitals are too afraid that they’ll go bankrupt if they stop taking Medicare funding. Medicare the bully is still winning. At some point, a couple of hospitals are going to stand up to the bully, punch him in the nose, and tell him to stick his paltry payments and all the micromanagement that goes along with them.

If those hospitals survive, others will undoubtedly follow, resulting in huge market shifts. Will lofty professors of specialty medicine remain with their university programs if suburban hospitals pay their specialists twice the salary that professors earn? What if there are one tenth of the documentation and administrative hassles? No JCAHO? Get paid more so you can spend more time with your patients?

Primary care physicians and their patients are finding concierge practices quite rewarding. It’s only a matter of time until a hospital takes the leap.

CMS may still be driving a Hummer when playing chicken with residency programs, but powerful hospital systems in affluent suburban areas might just be driving a Bradley Fighting Vehicle. One of these times, CMS is going to lose … and it will liberate the practice of medicine.

I can’t wait.