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What is required for "stabilization" for EMTALA is based on rather poorly defined "Medical Screening Examination (MSE)". So, there are no clear cut answer to your questions but rather requires the old "clinical judgement" (which never gets old to me!). A hemodynamically stable patient is stable in my opinion.


However, insurance "over reach" is not a new problem. For those in my age group will recall:


Back in the 90s, when HMOs first entered the market place, we regularly performed MSEs on patients in our EDs, then had to call the insurance companies for "permission" to provide care. Often, the HMOs denied permission and insisted that we transfer the patients to their own urgent care centers for evaluation. Since we were NOT initially reimbursed for these federally mandated medical screening exams, ED groups sued the insurance industry for payment for the MSEs and won. This changed everything in emergency medicine literally overnight; the HMOs no longer insisted on transfers to their own urgent care centers since the same urgent visit would now cost them "twice".


In addition, if they did grant permission for care in our ED, and ultimately the patient required admission, then the insurance company had to approve the admission to our facility or insist on a transfer to another hospital that had a contract with that HMO. Otherwise, the family was liable for the huge hospital bill. With nearly 20 HMOs in Dade County, Florida back then, this "song and dance" happened with regularity since the HMOs played physician vs. physician and hospital vs. hospital with negotiated fees, and not every "on call physician" or hospital accepted every plan.


Since that time, the number of HMOs in each particular market has dwindled to the point these events rarely happen when compared to the 90s. In addition, academic centers are rather insulated from all this since they often have contracts with nearly all of the major insurance companies in the region. So, only rarely do we need to transfer patients away from our hospital based solely on insurance restrictions.


I firmly beleive we can learn a lot by remembering history in the context of truth (very timely with the events of this past week): when we again hear the debate of "choice in the market place", I say: "remember the 90s!".


"Choice" of multiple insurance companies in your marketplace, vs. a single payer option like "Medicare for ALL", leads to much less "choice" for the consumers when they are actually in need of medical services.


I love the Netherlands but choose to stay and change things here.


Just my two cents.


Bob Flood

________________________________
From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Jacob Snow <[log in to unmask]>
Sent: Thursday, August 17, 2017 4:00:22 PM
To: [log in to unmask]
Subject: EMTALA, transfers, insurance

Question for the group.

I had a discussion today with hospital executives about a case in which one of our providers transferred a patient to another hospital in town on account of the patient's insurance not being contracted.  The transfer was lateral with regards to the medical capacity of the facilities involved.
Clinically, the patient was hemodynamically stable but had anemia requiring transfusion(s) and if admitted to our facility would have gone the the general pediatrics unit.  The anemia was not due to acute blood loss or acute hemolysis/consumption.
Our provider arranged for our pediatric critical care transfer team since the PRBC transfusion was already infusing.  The insurance is now arguing that the patient should have been transferred by a lower cost transport option, BLS or ALS.

The question arises was the child even "stable" for transfer?

Should (could) the provider deem the patient "unstable for transfer" given the need for PRBC and admit for transfusions at our hospital?

Should (could) the provider delay the transfusion, which the child needed, in order to accommodate a BLS/ALS transfer to an insurance contracted facility?

Should (could) the provider just move to the Netherlands and not worry about any of this ever again?

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