LISTSERV mailing list manager LISTSERV 16.5

Help for PED-EM-L Archives


PED-EM-L Archives

PED-EM-L Archives


PED-EM-L@LISTSERV.BROWN.EDU


View:

Message:

[

First

|

Previous

|

Next

|

Last

]

By Topic:

[

First

|

Previous

|

Next

|

Last

]

By Author:

[

First

|

Previous

|

Next

|

Last

]

Font:

Proportional Font

LISTSERV Archives

LISTSERV Archives

PED-EM-L Home

PED-EM-L Home

PED-EM-L  July 2004

PED-EM-L July 2004

Subject:

Re: FW: EMTALA question

From:

"Peter Glaeser, M.D." <[log in to unmask]>

Reply-To:

Peter Glaeser, M.D.

Date:

Tue, 13 Jul 2004 15:55:58 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (480 lines)

The list is probably already tired of this discussion so I will be
brief.

Yes I would appreciate any case law that has applied EMTALA to define
the standard of care in a free standing urgent care center.

Thanks for responding to the scenario.  You are correct that EMTALA was
made necessary because of a very small percentage of people who don't
"do the right thing." As Mitchell Farrell's response indicates, your
desired response is a likely one when someone presents with an obvious
emergency and are perceived as being at risk without immediate
intervention. That was probably the initial intent of EMTALA but we are
far from that now.  Any medical condition must be evaluated, no matter
how obvious it is that it is not an emergency or that no one is
reimbursing for the care provided...national health care does exist,
it's just being paid for by hospitals and hospital based physicians.

EMTALA is very poorly understood by many hospitals, physicians,
administrators and even CMS as evidenced by inconsistent regional
interpretations, and conflicting court decisions.  Back to our scenario
you responded to... an unintended consequence of EMTALA has been a
misinterpretation by hospitals and docs that the transporting facility
must fully evaluate and stabilize any patient using all resources
existing at the facility prior to transport...they miss the part "or
transfer" if benefits outweigh risks. We routinely receive transfers
from other parts of our state of severely traumatized children who get
total body CT scans despite the time consumed and the fact that they do
not have surgeons capable of acting on the results. When asked, they
often relate that EMTALA requires this and that other hospitals they
transfer (adult) patients to have threatened them with EMTALA reports if
"full work-up" not done.  The irony is that people who would normally
"do the right thing" anyway (without Government intervention) may end up
compromising patient care because of it, or be put at legal and
financial risk for a medically insignificant variance in process.

Okay so this wasn't brief!  Complex issue that sound bites can't cover.

Pete Glaeser


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Abigail Williams
Sent: Friday, July 09, 2004 4:56 PM
To: [log in to unmask]
Subject: Re: FW: EMTALA question

If I were walking in to a free standing urgent care center with chest
pain,
I would expect that someone would call an ambulance and attend to me as
best
they could while awaiting an ambulance, not tell me that "if you cant
pay
then you need to drive yourself to the nearest hospital....it happens
not
infrequently ...  And it is for that reason that the courts have looked
to
EMTALA - not to keep the patient there until you know what is wrong with
him
but certainly to treat the unfolding emergency appropriately i.e.
transferring the patient to the hospital....if you want specific cases I
would be happy to provide them for you.  It makes sense in a way, either
treat the emergency or if you cannot then send the patient out....do not
leave them in jeopardy over money...


Abigail Williams, RN, JD, MPH
Abigail Williams & Associates, PC
370 Main Street
Worcester, MA 01608
Phone: (508)795-1955
Fax:(508)795-1710
[log in to unmask]


-----Original Message-----
From: Peter Glaeser, M.D. [mailto:[log in to unmask]]
Sent: Friday, July 09, 2004 2:15 PM
To: Abigail Williams; [log in to unmask]
Subject: RE: Re: FW: EMTALA question

"EMTALA is used however to define the standard of care for a free
standing
center and I think that a compelling argument could be made in court
that a
person with chest pain who is sent out the door because of an inability
to
pay without being seen by a medical provider can hold the urgent care
center
to the "standard of care" that is represented by EMTALA even if the
statute
does not address non hospital based centers..."

When I read "EMTALA" and "standard of care" in the same sentence it
makes
the hair on my neck stand up! EMTALA is about process, not standard of
care.
I think that is probably what you mean, but maybe as an attorney on the
list
you have knowledge of case law of which I am unaware.  Can you cite
evidence
where EMTALA has been "used to define the standard of care for a free
standing center?"

A question for you and the group....if you were having chest pain, hx of
heart disease, shortness of breath etc., and walked into a free standing
urgent care center, would you want to be evaluated by the pediatrician
working there, wait for enzymes, ECG, etc., or have someone at the
center
call 911 and give you an aspirin? (the latter approach could be
construed as
an EMTALA violation depending on how it is orchestrated) Or how about a
real
case recently at a hospital in our community: patient in the hospital
jumps
out a window on the 6th story. The hospital is not a trauma center so
they
call EMS who respond quickly and transport to the trauma center.
Technically
this is an EMTALA violation, but it was the right thing to do for the
patient.

EMTALA has been expanded well beyond its original intent and has
unintended
consequences (the road to hell is paved with good intentions).
Suggesting
it be expanded further to make things more "fair" exposes the real
problem;
EMTALA is an unfunded mandate and band aid approach to a broken health
care
system.

Pete Glaeser



-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Abigail Williams
Sent: Friday, July 09, 2004 9:25 AM
To: [log in to unmask]
Subject: Re: FW: EMTALA question

The target of the legislature was hospitals when the original law was
passed.  The impetuous had at its root the court recognized public
policy of
detrimental reliance in the now famous Manlove case.  That is to say
that if
the patient sees a sign on the front of the hospital that states, in
effect,
come here with your emergency and we will care for you and then the
hospital
turns them away, they have relied on the representation of the hospital
to
their detriment and possibly lost valuable time in seeking care.  At
that
time, free standing urgent care centers were not prevalent and not
considered to have the same publicly recognized obligations to provide
emergency care as the hospitals.  It would seem fair that the for profit
free standing urgent care centers have the same obligation that the
hospital
does when advertising for the same services...i.e. we are here to care
for
your emergencies...but as of today, that has not been addressed by the
original law or any of the amendments..... Although it should
be...EMTALA is
used however to define the standard of care for a free standing center
and I
think that a compelling argument could be made in court that a person
with
chest pain who is sent out the door because of an inability to pay
without
being seen by a medical provider can hold the urgent care center to the
"standard of care" that is represented by EMTALA even if the statute
does
not address non hospital based centers...


Abigail Williams, RN, JD, MPH
Abigail Williams & Associates, PC
370 Main Street
Worcester, MA 01608
Phone: (508)795-1955
Fax:(508)795-1710
[log in to unmask]


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Maggie Huey
Sent: Thursday, July 08, 2004 7:23 PM
To: [log in to unmask]
Subject: Re: FW: EMTALA question

Food for thought:  How do the non hospital affiliated urgent care center
chains  continue to fall outside the EMTALA  coverage?  They certainly
meet
two of the three criteria listed below.  But it is my understanding that
there are no specific criteria that do govern  those facilities.

Maggie Huey, BSN, MHA
Director of Emergency Services
Cook Children's Med Ctr
Fort Worth, Tx

>>> "McDonnell, William" <[log in to unmask]> 07/08/04 12:06PM
>>> >>>
My comments were abbreviated for ease in reading, but were entirely
accurate.  An urgent care center affiliated with a hospital meets the
definition of a "dedicated emergency department" under the 2003 EMTALA
regulations if the facility is:
(1) licensed as an ED by the state; OR
(2) held out to the public as treating emergent or urgent conditions
without
an appointment; OR
(3) provides at least one-third of its outpatient visits on an urgent or
emergent basis, without requiring an appointment.

Labor and delivery units, psychiatric units, and off-campus hospital
urgent
care centers are specifically included within the description of
"dedicated
emergency departments" in the new EMTALA regulations.  For "dedicated
emergency departments," the 2003 Regulations dictate that all EMTALA
requirements apply (including that an appropriate medical screening exam
must be provided to any patient who requests examination or treatment
for
any medical condition.)

While it is possible that a few centers who call themselves "ED" or
"Urgent
Care" might not meet any of the criteria for designation as a "dedicated
emergency department," I stand by my original position that virtually
all
pediatric ED's and urgent care centers will be deemed "dedicated
emergency
departments" under the regulations.  Being "held out to the public as
treating emergent or urgent conditions without an appointment" is
sufficient
to qualify as a "dedicated emergency department," and simply using the
term
"urgent care center" may very well meet this condition.  Moreover, the
regulations have specifically included urgent care centers as "dedicated
emergency departments."

A traditional appointment-based clinic remains outside the scope of
EMTALA.
But it is a very bold urgent care center physician or medical director
who
refuses to comply with EMTALA.



-----Original Message-----
From: Peter Glaeser, M.D. [mailto:[log in to unmask]]
Sent: Thursday, July 08, 2004 9:51 AM
To: McDonnell, William; [log in to unmask]
Subject: RE: EMTALA question

"If your urgent care center is affiliated with a hospital and meets the
2003 EMTALA regulations' definition of a "dedicated emergency
department,"
(and virtually all pediatric ED's and hospital-affiliated urgent care
centers do meet this definition)"

This statement is not completely accurate. The urgent care clinic will
be
considered a "dedicated ED" only if over 1/3 of the yearly visits are
for
unscheduled emergencies.  If your clinic is referral/appointment only
and
your walk-ins are less than 1/3 of total (CMS will look at the year
prior),
then EMTALA does not apply.

It is interesting that the payor requires an ED copay; do they also then
compensate for visits as if an ED (include a facility charge in addition
to
M.D. bill)?

Pete Glaeser

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of McDonnell, William
Sent: Thursday, July 08, 2004 7:37 AM
To: [log in to unmask]
Subject: EMTALA question




        Dr. Zang:

        Your posting raises a number of important EMTALA issues.

        1.  It is crucial to recognize that your relationship
(contractual
or otherwise) with any insurer or managed care provider is absolutely
irrelevant to your EMTALA obligations.  If your urgent care center is
affiliated with a hospital and meets the 2003 EMTALA regulations'
definition
of a "dedicated emergency department," (and virtually all pediatric ED's
and
hospital-affiliated urgent care centers do meet this definition), then
you
assume the full complement of EMTALA obligations to ALL patients,
regardless
of how the insurer characterizes you.

        2.  It is absolutely unlawful under EMTALA to alter your
emergency
evaluation and stabilization of a patient based on his particular
insurer or
managed care provider.  Regardless of your contractual terms with the
insurer, you must provide the same medical screening exam and any
necessary
stabilization that you would for any other patient.  The EMTALA
regulations
are quite clear that refusing, limiting, or even delaying emergency
screening and stabilization in order to obtain managed care provider
approval, or in deference to the insurer's disapproval, is
impermissible.

        3.  An accurate disclosure of your costs and billing practices
is
not inappropriate.  Moreover, EMTALA specifically permits hospitals to
collect demographic and financial information, so long as it does not
delay
or interfere with emergency medical screening and stabilization.
However, it would be unlawful to make emergency screening and
stabilization
of any patient conditional on an up-front co-pay.  The delicate part
here is
that discussion of the co-pay, even if it will be collected later,
cannot be
done in such a way as to give the impression that evaluation and
stabilization is conditional on some initial payment.  Any information
you
provide on this issue must make it very clear that you will evaluate and
stabilize any emergency condition immediately, and that payment and
collection issues will be addressed later.

        Those with an interest in this area or who have questions about
the
new EMTALA regulations' effects on pediatric emergency practice may wish
to
see the upcoming August 2004 Pediatric Emergency Care for an article on
the
topic.

        William M. McDonnell, MD, JD
        The Childrens Hospital
        Denver, Colorado

                -----Original Message-----
                From: Pediatric Emergency Medicine Discussion List on
behalf
of Peter Zang
                Sent: Wed 7/7/2004 7:05 PM
                To: [log in to unmask]
                Cc:
                Subject: EMTALA question



                I work at a free standing urgent care clinic.  One
insurance
provider will not recognize us as an urgent care center (it is in the
contract with them) and their patients must pay an ER copay, even though
their plan lists an urgent care copay.  As you can imagine, some
families
are not too happy when they realize this.
                My question is whether we can place a sign at the front
desk
explaining the situation, or would that be construed as violating
EMTALA's
restrictions on asking for financial information before a patient is
seen?
Is there a way of phrasing it to avoid any problems?
                Any suggestions would be helpful.  Fell free to reply to
my
personal email - [log in to unmask]<mailto:[log in to unmask]>

                For more information, send mail to
[log in to unmask] with the message: info PED-EM-L
                The URL for the PED-EM-L Web Page is:

http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html




DISCLAIMER:
CONFIDENTIALITY NOTICE:  The information contained in this message is
legally privileged and confidential information intended for the use of
the
individual or entity named above. If the reader of this message is not
the
intended recipient, or the employee or agent responsible to deliver it
to
the intended recipient, you are hereby notified that any release,
dissemination, distribution, or copying of this communication is
strictly
prohibited.  If you have received this communication in error, please
notify
the author immediately by replying to this message and delete the
original
message. Thank you.

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html



DISCLAIMER:
CONFIDENTIALITY NOTICE:  The information contained in this message is
legally privileged and confidential information intended for the use of
the
individual or entity named above. If the reader of this message is not
the
intended recipient, or the employee or agent responsible to deliver it
to
the intended recipient, you are hereby notified that any release,
dissemination, distribution, or copying of this communication is
strictly
prohibited.  If you have received this communication in error, please
notify
the author immediately by replying to this message and delete the
original
message. Thank you.

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

*****************************************************************
Cook Children's Health Care System

This e-mail, facsimile, or letter and any files or attachments
transmitted
may contain information that is confidential and privileged. This
information is intended only for the use of the individual(s) and
entity(ies) to whom it is addressed. If you are the intended recipient,
further disclosures are prohibited without proper authorization. If you
are
not the intended recipient, any disclosure, copying, printing, or use of
this information is strictly prohibited and possibly a violation of
federal
or state law and regulations.

If you have received this information in error, please notify Cook
Children's Health Care System immediately at (682)885-4000 or via e-mail
at
[log in to unmask] Cook Children's Health Care System, its
subsidiaries, and affiliates hereby claim all applicable privileges
related
to this information.
*****************************************************************

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

Top of Message | Previous Page | Permalink

Advanced Options


Options

Log In

Log In

Get Password

Get Password


Search Archives

Search Archives


Subscribe or Unsubscribe

Subscribe or Unsubscribe


Archives

July 2019
June 2019
May 2019
April 2019
March 2019
February 2019
January 2019
December 2018
November 2018
October 2018
September 2018
August 2018
July 2018
June 2018
May 2018
April 2018
March 2018
February 2018
January 2018
December 2017
November 2017
October 2017
September 2017
August 2017
July 2017
June 2017
May 2017
April 2017
March 2017
February 2017
January 2017
December 2016
November 2016
October 2016
September 2016
August 2016
July 2016
June 2016
May 2016
April 2016
March 2016
February 2016
January 2016
December 2015
November 2015
October 2015
September 2015
August 2015
July 2015
June 2015
May 2015
April 2015
March 2015
February 2015
January 2015
December 2014
November 2014
October 2014
September 2014
August 2014
July 2014
June 2014
May 2014
April 2014
March 2014
February 2014
January 2014
December 2013
November 2013
October 2013
September 2013
August 2013
July 2013
June 2013
May 2013
April 2013
March 2013
February 2013
January 2013
December 2012
November 2012
October 2012
September 2012
August 2012
July 2012
June 2012
May 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September 2011
August 2011
July 2011
June 2011
May 2011
April 2011
March 2011
February 2011
January 2011
December 2010
November 2010
October 2010
September 2010
August 2010
July 2010
June 2010
May 2010
April 2010
March 2010
February 2010
January 2010
December 2009
November 2009
October 2009
September 2009
August 2009
July 2009
June 2009
May 2009
April 2009
March 2009
February 2009
January 2009
December 2008
November 2008
October 2008
September 2008
August 2008
July 2008
June 2008
May 2008
April 2008
March 2008
February 2008
January 2008
December 2007
November 2007
October 2007
September 2007
August 2007
July 2007
June 2007
May 2007
April 2007
March 2007
February 2007
January 2007
December 2006
November 2006
October 2006
September 2006
August 2006
July 2006
June 2006
May 2006
April 2006
March 2006
February 2006
January 2006
December 2005
November 2005
October 2005
September 2005
August 2005
July 2005
June 2005
May 2005
April 2005
March 2005
February 2005
January 2005
December 2004
November 2004
October 2004
September 2004
August 2004
July 2004
June 2004
May 2004
April 2004
March 2004
February 2004
January 2004
December 2003
November 2003
October 2003
September 2003
August 2003
July 2003
June 2003
May 2003
April 2003
March 2003
February 2003
January 2003
December 2002
November 2002
October 2002
September 2002
August 2002
July 2002
June 2002
May 2002
April 2002
March 2002
February 2002
January 2002
December 2001
November 2001
October 2001
September 2001
August 2001
July 2001
June 2001
May 2001
April 2001
March 2001
February 2001
January 2001
December 2000
November 2000
October 2000
September 2000
August 2000
July 2000
June 2000
May 2000
April 2000
March 2000
February 2000
January 2000
December 1999
November 1999
October 1999
September 1999
August 1999
July 1999
June 1999
May 1999
April 1999
March 1999
February 1999
January 1999
December 1998
November 1998
October 1998
September 1998
August 1998
July 1998
June 1998
May 1998
April 1998
March 1998
February 1998
January 1998
December 1997
November 1997
October 1997
September 1997
August 1997
July 1997
June 1997
May 1997
April 1997
March 1997
February 1997
January 1997
December 1996
November 1996
October 1996
September 1996
August 1996
July 1996
June 1996
May 1996
April 1996
March 1996
February 1996
January 1996
December 1995
November 1995
October 1995
September 1995
August 1995
July 1995
June 1995
May 1995
April 1995
March 1995
February 1995
January 1995
December 1994
November 1994
October 1994
September 1994

ATOM RSS1 RSS2



LISTSERV.BROWN.EDU

CataList Email List Search Powered by the LISTSERV Email List Manager