Waiting times in the age of EMTALA: The gulf between private and public/non-profit widens
2006; Elsevier BV; Volume: 47; Issue: 3 Linguagem: Inglês
10.1016/j.annemergmed.2006.01.028
ISSN1097-6760
Autores Tópico(s)Healthcare Policy and Management
ResumoBillboards and broadcast advertising in Michigan tout the Oakwood Hospital and Medical Center pledge–patients will receive emergency department (ED) treatment by a physician within a half-hour of arrival, or they’ll get two movie tickets and a personal apology by the hospital.“We’ll see you in 30,” the ad campaign proclaims. “We guarantee it!”A spokesman for the Dearborn-based chain of five hospitals says ED improvements mean that only a few theater tickets have had to be handed out.Similarly, the Medical Center of Southeastern Oklahoma is reporting successes from an even more ambitious marketing effort. The Durant hospital promises to perform emergency department triage no later than 15 minutes after arrival. If the wait extends beyond that, the center guarantees a free hospital room for the night.Other private hospital chains have launched similar campaigns to snare patients and potentially lucrative emergency department business, highlighting improvements and a new focus as efficient service providers.Largely nestled in middle and upper income suburbs, these hospitals can afford to be efficient. Nearly all of their patients have insurance, and the more patients they see the more profitable they become. Sitting in these well-appointed waiting rooms, it is easy to believe the system works, that everyone is seen in a timely fashion regardless of ability to pay, that no unstable indigent patient is shipped across town to the public hospital.This might have been what Congress had in mind when it passed the Emergency Medical Treatment and Labor Act of 1985 (EMTALA), but they represent only a small percentage of the patients seeking care in EDs. Commonly known as the “antipatient-dumping” law, EMTALA has come to mean that EDs must provide prompt medical screening exams to all who seek treatment, regardless of their insurance standing and regardless of their complaint. They must also stabilize patients with medical emergencies, provide suitable transfers and provide on-call specialists for any additional required services. EMTALA, an amendment to the Consolidated Omnibus Budget Reconciliation Act (COBRA), levied $50,000 fines for violations by hospitals and doctors that participate in Medicare (or similarly federally funded programs).It took another 10 years before the law was given any teeth. Congressional action in 1996 allocated adequate funding for the Department of Health and Human Services and the Department of Justice to investigate the 200 or so complaints received annually from patients. In the two years following enforcement funding, the government collected penalties of $2.3 million in settlements of 67 dumping cases, exceeding the settlements and penalties collected in the first ten years of the law.Fluent in the federal lexiconNow, every ED in the country is well versed in the language of EMTALA. While medical authorities criticized the often-cumbersome regulatory requirements and the still-debated legal interpretations of the act, many say it contained reforms that were long overdue.“I think largely it did what it was intended to do,” said Dr. Guy Clifton, chair of the Houston advocacy group called Save Our ER’s Coalition. “When that bill was passed, the abuses of uninsured patients were intolerable.”Clifton says it is hardly a perfect piece of legislation, “but it certainly reduced the most egregious violations of medical ethics.”Despite the effort to even out the funnel effect on public hospitals, government and non-profit hospitals bear the brunt of the squeeze on emergency care. Theater tickets and free hospital rooms are not an option, and 30-minute door-to-physician times are an impossibility, except for the most critical patients. A 2003 study by the American Hospital Association reported that non-profits handled more than 70 percent of ED cases. Hospitals operated by state or local governments served another 16.5 percent of those needing ED care, and for-profit hospitals treated less than 13 percent of the overall ED traffic.Even the early proponents of EMTALA acknowledge it was a stop-gap measure and admit to a little naiveté.Band-aid on a hemorrhage“(EMTALA) was never intended to be more than a Band-aid on a gaping wound,” said Dr. Art Kellermann, an emergency physician who testified at the early Congressional hearings on patient dumping. “At the time I was advocating for the law, I was warned by ACEP (American College of Emergency Physicians) colleagues that once the government got involved in regulating inter-hospital transfers, it wouldn’t stop at only restricting the most severe acts of patient dumping. With my youthful idealism, I thought they were paranoid. I was wrong.”It would seem that stopping patient dumping would ease the burden on public and non-profit hospitals, maybe even shorten waiting times for their patients, but quite the opposite has happened.In 1998, the administration of then-President Bill Clinton had to issue a directive, known as a special advisory bulletin, requiring hospitals to not ask about an ED patient’s insurance coverage or finances before they were seen by a doctor, examined and stabilized.“Clearly the executive branch in the Clinton years dramatically and in many ways inappropriately expanded the scope of the law,” Kellermann said. “In effect, it’s America’s answer to universal access to health care–and a huge unfunded mandate on emergency physicians, trauma surgeons, on-call specialists and hospitals.”The law’s requirement that everyone who arrives at an ED must receive “a medical screening exam” to see if an emergency condition exists has become the devil in the details for public and non-profit hospitals.“It’s a little bit of a Frankenstein’s monster,” Kellermann said.It has been interpreted to mean emergency physicians or their extenders, such as physician assistants, must see every patient who walks through the door, from medication refills to heart attacks, and it has lengthened waiting times interminably.But Kellermann argues EMTALA is a minor influence on walk-in, non-emergent use of EDs. More important, he says, are the waiting times to get an appointment at a doctor’s office, which can stretch from weeks to months, even for urgent medical conditions and even for paying customers.“You have doctors saying, ‘Gosh, it’s Saturday. Go to the ER,’ or, “We close in an hour. Go to the ER,’” he said. “The person will learn from experience. Once you’ve tried three or four times, and you can’t get in for three or four months, the next time you’re not going to waste your time. You’re going to go straight to the ER.”The court of last appealHowever, the federal mandate that EDs medically screen every patient does make them the court of last appeal for patients seeking care, regardless of the urgency of their condition.Some overwhelmed EDs have responded by putting a physician or physician’s assistant in triage to provide the screening exam and divert non-emergent patients to clinic systems, which are often backlogged.“Basically, this says, “You’re not sick enough to be here. Go away. Here’s a list of clinics’,” Kellermann said. “I’m opposed to this strategy … If you tell people, ‘Don’t come here unless you’re sick as hell,’ that’s what they’ll do.”Recently, President George W. Bush’s administration expanded exemptions to EMTALA in reaction to complaints of confusing hospital standards and responsibilities regarding on-call specialists.“The overall effect of this final rule will be to reduce the compliance burden for hospitals and physicians,” Bush officials stated in the Federal Registry.The action exempted the requirements of EMTALA for ED patients once they had been admitted as inpatients at hospitals. And it allowed specialists to be on-call for multiple hospitals at the same time, and provided exemptions from on-call duties for the senior medical staffs.The crisis of the uninsuredAside from the presidential edicts adjusting EMTALA, the nation’s ED advocates are pressing Congress for more legislative reforms to stave off what is being called a crisis.ACEP released a study in 2003 that summarized the concerns. An estimated 45 million Americans have no health insurance whatsoever, with millions more going uninsured periodically. They, and patients covered only by Medicaid or federal children’s insurance, account for more than one in every three ED patients.ED visits themselves have been increasing at a rate of two million annually over the past decade, totaling almost 114 million in 2003. And yet, over the last decade the number of hospital EDs has declined by more than 14 percent, ACEP surveys showed.Nationally, there were 382 ED visits per 1,000 population in 2003, the American Hospital Association reported. The study noted that several states in the lower economic tiers had significantly higher rates of ED use: Louisiana had 552 visits per 1,000 population; Mississippi had 543; Kentucky had 516; and the District of Columbia led the study with 620 visits.The statistics were among those aired in Congress as the basis for introducing the Access to Medical Services Act of 2005, authored by U.S. Representative Bart Gordon, a Tennessee Democrat.“Strain on emergency departments is due to multiple factors, including the shortage of nurses, a decrease in the total number of community hospitals, and high levels of bad debts incurred as a result of providing care to indigent patients,” Gordon states in the bill.It is designed to help stop the boarding of ED patients, reduce the lengthy waits, stem the financial losses by boosting Medicare ED compensation by 10 percent, and have some of the malpractice liability risks picked up by the federal government.Last October, the proposed act, House Resolution 3875, was referred to the U.S. House Subcommittee on Health. It has picked up six co-sponsors and has been endorsed by several medical organizations such as ACEP and the Emergency Nurses Association.“Soaring health care costs, reduced hospital budgets, and an increasing dependence on emergency care means that patients line the halls, waiting hours –sometimes days–to be transferred to inpatient hospital beds,” said Dr. Frederick Blum, ACEP president. “This is a daily occurrence in many hospitals, and our patients can’t wait any longer for Congress to act.”Gordon says the measures in the bill are needed to safeguard the basic survival of EDs.“Access to emergency departments is critical in our communities, but too many ERs are overcrowded, understaffed and underfunded,” he says. “My bill takes the necessary steps to ensure that emergency departments will be there to provide urgent medical care to those who need it.”A poor state of affairsThe states also have tried and failed to address the growing problem. Texas and Nevada illustrate the pitfalls.Texas has the highest percentage of uninsured people in America, more than one in four, according to 2001 statistics. As chair of the Houston advocacy group called Save Our ERs, neurosurgeon Guy Clifton is among those pressing Texas legislators to restore some $170 million in state funding frozen from paying for basic trauma care.He explains that nearly 1 in 3 trauma and ED patients is uninsured. “We’re not alone, but we’re one of the worst cities in terms of safety net services. There are only 15 clinics for about 1 million uninsured people, and a total of only about 17 operating rooms in the public hospital system.“So we’ve got a million people dependent upon emergency rooms for care – we’re their only source of care. That’s the problem.”Clifton argues his case against the state’s current political policies regarding health care. Texas ranks 44th in public spending for health services and is dead last in the percentage of children and adults who are insured.The building industry, along with retail sales and landscaping companies, are major employers, and yet they “typically do not provide insurance for their lower wage workers,” he says. “So the nature of business in Texas results in a lot of workers without insurance.”Coupled with that, Texas ranks 44th in per capita Medicaid spending, “so we participate in Medicaid at the lowest level you can participate in,” Clifton says.He criticizes state officials in particular for their opposition to full funding for federally subsidized children’s health insurance and policies that discourage enrollment in such programs.“The one thing that we can do that makes complete sense is that every kid in the state that’s eligible for that insurance ought to be enrolled,” Clifton says. “Kids are a deal; they don’t cost a lot of money to insure. And the money spent is very cost effective in terms of immunization and prevention of disease.”Since 2003, about 175,000 children have been dropped from the insurance programs. That supposedly saved the state about $200 million in revenue, but it cost Texas about $536 million in lost matching federal funds, he noted.His disgust was apparent in a November op-ed article in the Houston Chronicle: “Our state legislators will not tell the public that they do not have enough money to run the state,” Clifton wrote. “Extreme political ideology masquerades as fiscal conservatism. Common sense speaks against refusing to spend one state dollar on children’s health care so that we can bring in more than twice that in federal health-care dollars.”The result, Clifton says, is that the state legislature effectively dumps the real costs on the insured and the employers who contribute to their workers’ insurance coverage. It adds about 13 percent to the health premium costs “because our hospitals cost-shift to finance uninsured care,” Clifton concluded.The action by legislators was especially criticized because state lawmakers had acted to relieve the problem only two years earlier. They passed a bill that added fees to traffic tickets that generated about $180 million to offset trauma care costs for the uninsured. That reversed the Texas hospital trend of cutting back or eliminating trauma care to avoid an estimated $260 million in losses for that service.After the 2003 bill to create the trauma fund, 70 more hospitals submitted applications to become trauma centers in Texas. When legislators froze some $170 million from that fund this year, some of those hospitals announced they were again closing their trauma centers.State Representative Tom Craddick, the speaker of the Texas House, led the effort to freeze the money for general fund use, saying the action was fiscally prudent.Clifton said it was irresponsible not to use the money for needed emergency care, and that the stated savings to the state were a fraction of Texas’ $117 billion annual budget.He closed his Chronicle article with a warning: “If, on a dark night you are injured on a Texas highway and there is no one to take care of you, call Tom Craddick.”A safe betEmergency departments became the arena for other political action on the state level in 2005. Nevada passed a law that called for patients arriving by ambulance to receive “emergency care and services” within 30 minutes at Nevada hospitals.However, lawmakers in the gambling state weren’t ready to risk high wagers on that guarantee being carried out. There was no penalty included for any hospital that took longer than a half-hour for such patients. Instead, the law established a process for reviews of cases exceeding that time limit, with quarterly reports to the legislature. It also set up an advisory committee to examine the problems.“Legislatures hope to achieve compliance by shaming hospitals when county health agencies release their findings,” an editorial groused in the Las Vegas Review-Journal, “all for some arbitrary 30-minute benchmark that has nothing to do with patient mortality. This bill won’t improve patient care. If anything, it will increase the cost of care and create longer waits for (non-ambulance) emergency room patients.”Federal cure for nation’s illWhile state officials debate emergency medical care actions, Houston’s Clifton and others point out that the magnitude of the problems and funding requirements dwarf the resources of local or even state governments.The price for adequate coverage for the one million uninsured Houston area residents would likely reach $1 billion, far more than what could ever be covered by area property taxes or even state revenue, Clifton says.“Patching up the emergency room function like we are all trying to do is just treating the symptom and not the problem,” he says. “I regard this fundamentally as a federal problem – it is only really manageable at the federal level.”Kellermann agrees and says emergency physicians have to be leaders in the call for a remedy.“(Patients) turn to us when they have no other option,” he said. “Most ACEP members understand that and feel a real moral obligation. There has to be a more broad-based approach to this than the Band-aid of EMTALA.” Billboards and broadcast advertising in Michigan tout the Oakwood Hospital and Medical Center pledge–patients will receive emergency department (ED) treatment by a physician within a half-hour of arrival, or they’ll get two movie tickets and a personal apology by the hospital. “We’ll see you in 30,” the ad campaign proclaims. “We guarantee it!” A spokesman for the Dearborn-based chain of five hospitals says ED improvements mean that only a few theater tickets have had to be handed out. Similarly, the Medical Center of Southeastern Oklahoma is reporting successes from an even more ambitious marketing effort. The Durant hospital promises to perform emergency department triage no later than 15 minutes after arrival. If the wait extends beyond that, the center guarantees a free hospital room for the night. Other private hospital chains have launched similar campaigns to snare patients and potentially lucrative emergency department business, highlighting improvements and a new focus as efficient service providers. Largely nestled in middle and upper income suburbs, these hospitals can afford to be efficient. Nearly all of their patients have insurance, and the more patients they see the more profitable they become. Sitting in these well-appointed waiting rooms, it is easy to believe the system works, that everyone is seen in a timely fashion regardless of ability to pay, that no unstable indigent patient is shipped across town to the public hospital. This might have been what Congress had in mind when it passed the Emergency Medical Treatment and Labor Act of 1985 (EMTALA), but they represent only a small percentage of the patients seeking care in EDs. Commonly known as the “antipatient-dumping” law, EMTALA has come to mean that EDs must provide prompt medical screening exams to all who seek treatment, regardless of their insurance standing and regardless of their complaint. They must also stabilize patients with medical emergencies, provide suitable transfers and provide on-call specialists for any additional required services. EMTALA, an amendment to the Consolidated Omnibus Budget Reconciliation Act (COBRA), levied $50,000 fines for violations by hospitals and doctors that participate in Medicare (or similarly federally funded programs). It took another 10 years before the law was given any teeth. Congressional action in 1996 allocated adequate funding for the Department of Health and Human Services and the Department of Justice to investigate the 200 or so complaints received annually from patients. In the two years following enforcement funding, the government collected penalties of $2.3 million in settlements of 67 dumping cases, exceeding the settlements and penalties collected in the first ten years of the law. Fluent in the federal lexiconNow, every ED in the country is well versed in the language of EMTALA. While medical authorities criticized the often-cumbersome regulatory requirements and the still-debated legal interpretations of the act, many say it contained reforms that were long overdue.“I think largely it did what it was intended to do,” said Dr. Guy Clifton, chair of the Houston advocacy group called Save Our ER’s Coalition. “When that bill was passed, the abuses of uninsured patients were intolerable.”Clifton says it is hardly a perfect piece of legislation, “but it certainly reduced the most egregious violations of medical ethics.”Despite the effort to even out the funnel effect on public hospitals, government and non-profit hospitals bear the brunt of the squeeze on emergency care. Theater tickets and free hospital rooms are not an option, and 30-minute door-to-physician times are an impossibility, except for the most critical patients. A 2003 study by the American Hospital Association reported that non-profits handled more than 70 percent of ED cases. Hospitals operated by state or local governments served another 16.5 percent of those needing ED care, and for-profit hospitals treated less than 13 percent of the overall ED traffic.Even the early proponents of EMTALA acknowledge it was a stop-gap measure and admit to a little naiveté. Now, every ED in the country is well versed in the language of EMTALA. While medical authorities criticized the often-cumbersome regulatory requirements and the still-debated legal interpretations of the act, many say it contained reforms that were long overdue. “I think largely it did what it was intended to do,” said Dr. Guy Clifton, chair of the Houston advocacy group called Save Our ER’s Coalition. “When that bill was passed, the abuses of uninsured patients were intolerable.” Clifton says it is hardly a perfect piece of legislation, “but it certainly reduced the most egregious violations of medical ethics.” Despite the effort to even out the funnel effect on public hospitals, government and non-profit hospitals bear the brunt of the squeeze on emergency care. Theater tickets and free hospital rooms are not an option, and 30-minute door-to-physician times are an impossibility, except for the most critical patients. A 2003 study by the American Hospital Association reported that non-profits handled more than 70 percent of ED cases. Hospitals operated by state or local governments served another 16.5 percent of those needing ED care, and for-profit hospitals treated less than 13 percent of the overall ED traffic. Even the early proponents of EMTALA acknowledge it was a stop-gap measure and admit to a little naiveté. Band-aid on a hemorrhage“(EMTALA) was never intended to be more than a Band-aid on a gaping wound,” said Dr. Art Kellermann, an emergency physician who testified at the early Congressional hearings on patient dumping. “At the time I was advocating for the law, I was warned by ACEP (American College of Emergency Physicians) colleagues that once the government got involved in regulating inter-hospital transfers, it wouldn’t stop at only restricting the most severe acts of patient dumping. With my youthful idealism, I thought they were paranoid. I was wrong.”It would seem that stopping patient dumping would ease the burden on public and non-profit hospitals, maybe even shorten waiting times for their patients, but quite the opposite has happened.In 1998, the administration of then-President Bill Clinton had to issue a directive, known as a special advisory bulletin, requiring hospitals to not ask about an ED patient’s insurance coverage or finances before they were seen by a doctor, examined and stabilized.“Clearly the executive branch in the Clinton years dramatically and in many ways inappropriately expanded the scope of the law,” Kellermann said. “In effect, it’s America’s answer to universal access to health care–and a huge unfunded mandate on emergency physicians, trauma surgeons, on-call specialists and hospitals.”The law’s requirement that everyone who arrives at an ED must receive “a medical screening exam” to see if an emergency condition exists has become the devil in the details for public and non-profit hospitals.“It’s a little bit of a Frankenstein’s monster,” Kellermann said.It has been interpreted to mean emergency physicians or their extenders, such as physician assistants, must see every patient who walks through the door, from medication refills to heart attacks, and it has lengthened waiting times interminably.But Kellermann argues EMTALA is a minor influence on walk-in, non-emergent use of EDs. More important, he says, are the waiting times to get an appointment at a doctor’s office, which can stretch from weeks to months, even for urgent medical conditions and even for paying customers.“You have doctors saying, ‘Gosh, it’s Saturday. Go to the ER,’ or, “We close in an hour. Go to the ER,’” he said. “The person will learn from experience. Once you’ve tried three or four times, and you can’t get in for three or four months, the next time you’re not going to waste your time. You’re going to go straight to the ER.” “(EMTALA) was never intended to be more than a Band-aid on a gaping wound,” said Dr. Art Kellermann, an emergency physician who testified at the early Congressional hearings on patient dumping. “At the time I was advocating for the law, I was warned by ACEP (American College of Emergency Physicians) colleagues that once the government got involved in regulating inter-hospital transfers, it wouldn’t stop at only restricting the most severe acts of patient dumping. With my youthful idealism, I thought they were paranoid. I was wrong.” It would seem that stopping patient dumping would ease the burden on public and non-profit hospitals, maybe even shorten waiting times for their patients, but quite the opposite has happened. In 1998, the administration of then-President Bill Clinton had to issue a directive, known as a special advisory bulletin, requiring hospitals to not ask about an ED patient’s insurance coverage or finances before they were seen by a doctor, examined and stabilized. “Clearly the executive branch in the Clinton years dramatically and in many ways inappropriately expanded the scope of the law,” Kellermann said. “In effect, it’s America’s answer to universal access to health care–and a huge unfunded mandate on emergency physicians, trauma surgeons, on-call specialists and hospitals.” The law’s requirement that everyone who arrives at an ED must receive “a medical screening exam” to see if an emergency condition exists has become the devil in the details for public and non-profit hospitals. “It’s a little bit of a Frankenstein’s monster,” Kellermann said. It has been interpreted to mean emergency physicians or their extenders, such as physician assistants, must see every patient who walks through the door, from medication refills to heart attacks, and it has lengthened waiting times interminably. But Kellermann argues EMTALA is a minor influence on walk-in, non-emergent use of EDs. More important, he says, are the waiting times to get an appointment at a doctor’s office, which can stretch from weeks to months, even for urgent medical conditions and even for paying customers. “You have doctors saying, ‘Gosh, it’s Saturday. Go to the ER,’ or, “We close in an hour. Go to the ER,’” he said. “The person will learn from experience. Once you’ve tried three or four times, and you can’t get in for three or four months, the next time you’re not going to waste your time. You’re going to go straight to the ER.” The court of last appealHowever, the federal mandate that EDs medically screen every patient does make them the court of last appeal for patients seeking care, regardless of the urgency of their condition.Some overwhelmed EDs have responded by putting a physician or physician’s assistant in triage to provide the screening exam and divert non-emergent patients to clinic systems, which are often backlogged.“Basically, this says, “You’re not sick enough to be here. Go away. Here’s a list of clinics’,” Kellermann said. “I’m opposed to this strategy … If you tell people, ‘Don’t come here unless you’re sick as hell,’ that’s what they’ll do.”Recently, President George W. Bush’s administration expanded exemptions to EMTALA in reaction to complaints of confusing hospital standards and responsibilities regarding on-call specialists.“The overall effect of this final rule will be to reduce the compliance burden for hospitals and physicians,” Bush officials stated in the Federal Registry.The action exempted the requirements of EMTALA for ED patients once they had been admitted as inpatients at hospitals. And it allowed specialists to be on-call for multiple hospitals at the same time, and provided exemptions from on-call duties for the senior medical staffs. However, the federal mandate that EDs medically screen every patient does make them the court of last appeal for patients seeking care, regardless of the urgency of their condition. Some overwhelmed EDs have responded by putting a physician or physician’s assistant in triage to provide the screening exam and divert non-emergent patients to clinic systems, which are often backlogged. “Basically, this says, “You’re not sick enough to be here. Go away. Here’s a list of clinics’,” Kellermann said. “I’m opposed to this strategy … If you tell people, ‘Don’t come here unless you’re sick as hell,’ that’s what they’ll do.” Recently, President George W. Bush’s administration expanded exemptions to EMTALA in reaction to complaints of confusing hospital standards and responsibilities regarding on-call specialists. “The overall effect of this final rule will be to reduce the compliance burden for hospitals and physicians,” Bush officials stated in the Federal Registry. The action exempted the requirements of EMTALA for ED patients once they had been admitted as inpatients at hospitals. And it allowed specialists to be on-call for multiple hospitals at the same time, and provided exemptions from on-call duties for the senior medical staffs. The crisis of the uninsuredAside from the presidential edicts adjusting EMTALA, the nation’s ED advocates are pressing Congress for more legislative reforms to stave off what is being call
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