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EMTALA; We Are Fa-mi-ly

EMTALA; We Are Fa-mi-ly.

In the late 1970's, emergency departments all over the United States not only triaged patients for illness, but also for their ability to pay the bill for emergency services. It was not an uncommon activity for private hospitals to transfer indigent patients to county and city hospitals to avoid the loss of revenue for caring for them. That is why the Regional Medical Center at Memphis was established: to shoulder the burden of indigent care so that the large private hospitals could enjoy large financial margins.

Unfortunately, many of these indigent patients were unstable and died or lost their babies (if they were in labor) in the transfer process. Hospitals in general cared not. Emergency physicians were complicit in the transfers since they did not want to provide care without compensation. In the late seventies and early eighties, federal legislation was initiated to stop hospital emergency rooms' Hot Potato mentality related to indigent patients. In the mid-1980's, EMTALA (Emergency Medical Treatment and Labor Act) was passed. It requires hospital emergency departments to evaluate, stabilize and treat any patient who walks through the threshold of their department seeking care, regardless of their ability to pay, severity of their illness or other grounds of discrimination.

Interestingly enough, Memphis was the scene of an EMTALA violation that reached national notoriety. Baptist East hospital was involved as well as The Med. The emergency department medical director at The Med, a University of Tennessee, College of Medicine faculty member filed charges against Baptist East's Emergency Physician, a University of Tennessee, College of Medicine resident (who was moonlighting) for transferring an indigent patient to the Med without notifying the emergency room physician. The patient required urgent surgery. On the surface, it appeared that the Baptist East emergency physician was violating federal law, but once the investigation was concluded, there were many disturbing factors in both Hospital systems and the University of Tennessee, College of Medicine. I believe Baptist paid a large price both economically and emotionally. The emergency department medical director at the Med launched his academic career from the incident. He ultimately took a job at Emory in Atlanta. I suspect the University of Tennessee said "good riddens" since they had to endure a large amount of egg on their faces as did the Baptist Hospital.

Why does any of this matter now? Because U.S. Representative Diane Black R-Gallatin, wants to get rid of the law. For some reason, the former nurse has forgotten the tragedies that befell many which resulted in enacting the law. She believes EMTALA is a burden that takes away clinicians ability to tell patients that an emergency room is not a proper place for treatment. She also is a Republican gubernatorial candidate for the State of Tennessee.

When I was the Chairperson of Emergency Medicine at the Med, we instituted a triage out program that cut the emergency department visits from 70,000 per year to 21,000. The mechanism is there within the law to provide a screening exam and immediate disposition. If the potential patient does not have an emergency, they can be triaged to the street without significant economic burden placed on the emergency department. But when we cut 50,000 visits from the emergency department, we cut massive revenue generation too. At that time, the Med's administration instructed me to create and maintain the program. All of those administrators are gone since they had no real understanding of the emergency department and what it meant to their success in the community. These were the same administrators who closed the coronary care unit and refused to treat heart attacks that walked through the doors. They are all gone thank goodness.

When EMTALA was enacted, hospital administrators decided to make their emergency departments community health clinics. Emergency Medicine training programs began lobbying for Emergency Medicine to be labeled a primary care specialty instead of a subspecialty of medicine. I had many heated political discussions specifically demanding that emergency medicine remain a subspecialty and not become a primary care field like Family Practice, Internal Medicine, Pediatric Medicine and OB-GYN. However, I was out voted in every venue. Ultimately the decision was made by the American Board of Medical Specialties that Emergency Medicine was NOT a primary care specialty. Funding was cut to residencies all across the country. However, hospital administrators continued to encourage patients to visit their emergency departments for any medical ailment, regardless of its severity or perceived life threat. At the present moment, anyone in Memphis can schedule a appointment through the internet in one of the local emergency departments for any reason.

If truth be told, the emergency department physicians treat on average less than ten true medical emergencies a day unless they are working in a trauma center. Even the busiest emergency departments in the country see very few strokes, heart attacks and life threatening medical emergencies. Although kidney stones and migraine headaches are extremely painful and require pain medication as well as intravenous fluids, they are not life threatening medical events. How does one characterized a true emergency? I am certain U.S. Representative Diane Black has little insight into modifying the law although some lobbyist organization has her ear, maybe even her pocketbook.

I believe the push to repeal the law is something that hospital administrators want. I am certain emergency physicians do not want to change it, for they generate huge dollars on minor medical care. Non-emergent care pays for emergency department staffing on both the physician and hospital sides. Medicare® use to reimburse less than fifty dollars for running a full code in an emergency department. How many people over the age of sixty-five were actually given a serious and complete resuscitation during their full cardiac arrest for fifty dollars? I think you know the answer.

The reality is that patients who are chronically ill are given little or no attention at all by their primary and specialty physicians. No one works to keep them healthy, their physicians and physician extenders spend less than ten minutes with them to handle their chronic recurrent complaints. The practice construct is to ignore the disease related complaints so they can go on to the next patient waiting in the office. Their mantra is: Let someone else on the medical team handle the health issues because it's too inconvenient today to help the patient for tomorrow.

Why? Because the current medical practice model is flawed. Reimbursement is based on everything but a healthy patient. Physicians and physician extenders on average see forty-five to sixty patients a day. No patient gets the care they need. No patient can walk into their physician’s office when they need a quick tune up. Their only resort is to go to the emergency department when something is out of sorts. Why? Because their physician's office staff tells them to go there because they are too busy to provide care. It's much too inconvenient. What is convenient to the majority of the physician offices open from 9:00 am to 5:00 pm? Go to the ER for care for your exacerbations of your chronic diseases.

EMTALA was a law that loudly identified that all people residing in America have the right to emergency and accident care and women can labor safely and securely regardless of your ability to pay. Emergency care which is one small piece of the healthcare pie, is a right bestowed to the public. The rest of healthcare according to most of the people I've spoken to, is a privilege that is afforded to those who can pay for it. And even if you can afford the privilege, there is no assurance that your care will be effective and/or safe since it is inconvenient to get high quality care you deserve on a routine basis.

Unless you're a member of the Stone Family.  We are Fa-mi-ly.


Posted by Amanda Sanders at 11:50 AM
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