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Archive for the ‘EMTALA’ Category

Do Hospital Policies to Deter Potential Drug Seekers Violate EMTALA?

Wednesday, April 17th, 2013

Interesting issue brought to my attention by a reader in South Carolina.

One of the hospitals in South Carolina wanted to post a sign in its emergency department waiting room stating the following:

Prescribing Pain Medication in the Emergency Department

Our Emergency Department staff understands that pain relief is important when one is hurt or needs emergency care. However, providing pain relief is often a complex issue, especially when pain is a chronic or recurrent process. Mistakes or misuses of pain medication can cause serious health problems and even death. Our Emergency Department will only provide pain relief options that are safe and appropriate.
• The primary role of the Emergency Medicine provider is to look for and treat an emergency medical condition. We will use our best medical judgment when treating pain, following all legal and ethical guidelines.
• You may be asked about a history of pain medication use, misuse, or substance abuse before prescribing any pain medication.
• We may ask you to show a photo ID, such as a driver’s license, when you check into the Emergency Department or receive a prescription for pain medications. We may also research the statewide prescription data base regarding your prescription drug use.
• We may only provide enough pain medication to last until you can contact your doctor. We will prescribe pain medications with a lower risk of addiction and/or overdose when possible.

 For your safety, we do not:
– Give pain medication shots for sudden increases in chronic pain, or aggravation of chronic pain syndromes.
– Refill lost or stolen prescriptions for medications. You must obtain refill prescriptions from your primary care provider or pain clinician.
– Prescribe missed methadone doses, or provide prescription refills for chronic pain management.
– Prescribe long-acting pain medications, such as OxyContin, MSContin, fentanyl patches, or methadone for chronic, non-cancer pain.
– Prescribe pain medications if you already receive pain medication from another doctor or emergency department.

The Centers for Medicare and Medicaid Services (CMS) had a different take.

EMTALA requires that every patient seeking care in the emergency department receive a “screening exam” and then receive “stabilizing treatment” of any emergency medical condition. In other words, if you are having a heart attack, the emergency department is required to stabilize you regardless of your ability to pay. If you have a runny nose or other non-emergency condition, the emergency department still has to examine you, but then doesn’t have to treat you. In either case, the hospital isn’t allowed to discourage you from seeking care.

CMS therefore wrote a letter to the South Carolina Hospital Association [.pdf file] and advised it that hospitals displaying such a sign would likely “unduly coerce [patients with legitimate medical needs] to leave the ED before receiving an appropriate medical screening exam.” Therefore, CMS considered such signs as potentially constituting an EMTALA violation.

I disagree with a lot of things about EMTALA. It is an unfunded mandate. Its reach has progressed far beyond the initial intent of the statute. But unless and until we repeal it, we are stuck with it.

I’m interested in your opinion, though.

Should a sign like the one above be considered an EMTALA violation?
Is it any different than hospitals that advertise their wait times? After all, a patient with an emergency medical condition may see the advertised wait time as being too long and might not go to a hospital because of it.

Vote below and leave a comment.

Should signs discouraging potential drug seeking patients from coming to the emergency department be considered an EMTALA violation?

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Dialysis and the Right to Health Care

Wednesday, December 16th, 2009

According to this Article from the Atlanta Journal Constitution, a court has ruled that at least some health care is not a right.

In October, I linked to an article about how Grady Memorial Hospital in Atlanta was closing its dialysis clinics due to the significant financial burden. Grady has agreed to pay for the patients to receive dialysis at a private dialysis clinic until January 3, 2010, but after that, the patients are on their own.

After Grady’s announcement, approximately 50 illegal immigrants sued to keep the clinic open, alleging that closing of the clinic “violated their constitutional right to the health care service” and that closing the clinic amounted to “medical abandonment.”

The court held that the plaintiffs had neither a state nor a federal constitutional right to outpatient dialysis services and that Grady Memorial was not legally bound to provide those services.

The attorney representing the patients stated that she realizes that some people don’t believe the patients are entitled to such care because they are illegal immigrants. “They are human beings, and we all have the right to live.” The attorney also stated that “these people are going to die without this.”

The lawyer misrepresented the plight of the patients. Under current federal law, renal failure patients will always have access to hemodialysis, and that access will likely be more expensive than the current system that Grady uses. I called this one seven months ago.

High levels of potassium in a dialysis patient is an emergency medical condition. Under federal EMTALA laws, hospitals are required to provide stabilizing treatment to anyone with an emergency medical condition that seeks medical care in an emergency department. All the patients have to do is call “911″ and they will get door-to-door service to the hospital via ambulance, will get a bunch of expensive testing done to document their elevated potassium, will likely be admitted to the hospital, and will still get their dialysis.

The situation raises a second question, though: Should we be providing uncompensated care to illegal aliens?

I think that the answer should be “yes” – with an asterisk.

If people are violating federal laws, they should suffer the same consequences as anyone else who violates any other federal law. In this case, provide the patients with dialysis, contact police, take the patients into custody, and then initiate deportation proceedings – or whatever other action is appropriate under federal law.

If hospital personnel become aware that a patient has committed a crime, we already call police from the emergency department.
A patient has a gunshot wound? We call the police to report it.
A patient may be the victim of domestic abuse? We file a police report.
A patient in a car accident has an elevated blood alcohol level? We notify the police.

How hard would it be to contact the police to verify someone’s identity if a patient is unable or unwilling to provide a state-issued identification? Not only would doing so determine whether or not a person is in the country legally, but it would cut down significantly on health care fraudsters who obtain care in the emergency department using a fictitious name and fictitious address and then stiff the hospital for the bill.

If we don’t want to enforce our laws, that’s fine.

Then we need to stop complaining about providing care to those who violate the laws.

Reducing Liability on EMTALA care

Wednesday, June 17th, 2009

Here I go with EMTALA again.

I wanted to flesh out an issue that Matt and Chris raised based on my previous post.

A proposed Ohio law states that a physician who provides emergency medical services is “not liable in damages to any person in a tort action for injury, death, or loss to person or property” based on the services unless there is “willful or wanton misconduct” involved (thanks to Max for the link).

Chris’ MedCity News published an article yesterday about the same law. The response from both sides of the issue is predictable. Malpractice plaintiff attorneys state that such a law would remove any incentives for quality control (as if JCAHO regulations suddenly wouldn’t apply once the law took effect). The Ohio Bar Association will come out with its official opinion in a couple of weeks, but for those of you who can’t stand the suspense, I can summarize it right now:

We believe that a law restricting the rights of citizens to sue is in direct conflict with the Constitution and would essentially give emergency physicians free reign to kill and maim the very subset of our population we should be protecting the most – those who are suffering from medical emergencies.

Proponents of such a law state that emergency physicians are “easy pickins” for lawsuits. They can’t refuse to evaluate any patient seeking care (unlike any other specialty – in fact, unlike any other profession that I can think of), the patients often come to the emergency department in extremis or with vague symptoms, there is usually little time to develop a physician patient relationship, there is very little follow up, oh, yeah, and if you don’t do everything the patient and family want and there is a bad outcome, they have the number to Dewey, Cheatem and Howe on their cell phone speed dial.

So allegedly, those physicians who provide emergency medical care (both emergency physicians and on-call specialists) are getting fed up with the threat of lawsuits and are leaving states where there is a high incidence of medical malpractice claims. I have not researched the issue, so I can’t cite any specific numbers.

The MedCity News article does cite a link about the projected shortfall of surgeons available to provide emergency care in Ohio. The MedCity News article also notes that many states have either passed or are considering such legislation including Arizona, Michigan, Minnesota, Utah, North Carolina, Florida, Georgia, Texas and South Carolina.

I commented on this topic in one of my posts on how to improve the house of medicine.

So in answer to Matt’s question about “why we would want a policy insulating ER docs from their negligence, even gross negligence,” I offer the following response from my previous post.

Granting medical providers immunity would throw everyone’s legal rights out the window, right? No profession should have immunity for their actions, should they? Funny. Judges have complete immunity for their actions. No one even questions the concept of “judicial immunity” any more. One quote I found here showed why the US Supreme Court feels that judicial immunity is important:

To render a judge liable to answer in damages to every litigant who feels aggrieved during the course of judicial proceedings, “would destroy that independence without which no judiciary can be either respectable or useful.” Bradley, 80 U.S. (13 Wall.) at 347.

It is OK for a judge to be grossly negligent and wholly biased in their duties. Litigants have no recourse whatsoever. The judges are immune from liability. At some point our nation is going to have to decide whether poor access to care, long waits for care and declining overall health is preferable to tort reform.

Perfect care or available care, Matt. You choose.

Will increasing the threshold of liability improve the practice of emergency medicine?

Have to wait for further data from states that have already enacted it. Anectdotally, Texas seems to be doing pretty well with its influx of physicians after implementing tort reform.

Newest EMTALA Violation?

Friday, June 5th, 2009

inquicker

One of the issues that sparked the blogfight between Scalpel and Nurse K was the “InQuickER” concept at the Emory Adventist Hospital Emergency Department in Smyrna, Georgia.

According to Emory’s web site, if you pay a $24.99 fee, you can reserve an “appointment” in the emergency department up to 12 hours in advance. You still have to pay for all of your care, but the $25 fee gets you on the “preferred” list. If you aren’t seen within 15 minutes of your appointment time by a physician or a physician’s assistant, you won’t pay for your services.

To “Hold My Place In Line“, all you have to do is enter your symptoms, your name, an e-mail address, and your payment information.

EMTALA requires that emergency departments provide a screening exam and that the screening examination be performed in a nondiscriminatory manner.

If Emory Adventist Hospital is cherry picking patients who have computers with internet connections, who have credit cards, and who can pay a $25 fee to get “In QuickEr”, wouldn’t that be considered just a lit-tle “discriminatory”?

Be interesting to see whether CMS jumps in if a patient who couldn’t afford the $25 copay had to sit longer at the back of the line and experienced a bad outcome.

If we are going to enforce this overbearing law, we have to do so uniformly.

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