Emergency Rooms Get Eased Rules on Patient Care

Nurses Activism



September 3, 2003

Emergency Rooms Get Eased Rules on Patient Care


WASHINGTON, Sept. 2-The Bush administration is relaxing rules that say hospitals have to examine and treat people who require emergency medical care, regardless of their ability to pay.

Under the new rule, which takes effect on Nov. 10, patients might find it more difficult to obtain certain types of emergency care at some hospitals or clinics that hospitals own and operate.

The new rule makes clear that hospitals need not have specialists "on call" around the clock. Some patients might have more difficulty winning damages in court for injuries caused by violations of the federal standards.

"The overall effect of this final rule will be to reduce the compliance burden for hospitals and physicians," the administration says in a preamble to the regulation, to be published next Tuesday in The Federal Register.

The administration drafted the new rule after hearing complaints from scores of hospitals and doctors who said the old standards were onerous and confusing, exposed them to suits and fines and encouraged people to seek free care in emergency rooms. Courts have often ruled for patients, and against hospitals.

In an interview, Thomas A. Scully, administrator of the federal Centers for Medicare and Medicaid Services, said tonight that the new standards would reduce the costs of compliance for hospitals and doctors without weakening patients' protection.

The new rule limits the scope of a law from 1986 that defines hospital obligations. It expands the situations in which hospitals are exempt from the federal requirements.

Mr. Scully said the 1986 law did "a lot of wonderful things, but also does some perverse things that cause a lot of heartburn for doctors and hospitals."

For example, Mr. Scully said, if a hospital has a cancer center or a dialysis center three blocks from its main building, the employees of the center have to be trained to deal with emergency cases, duplicating the work of the emergency room.

But Dr. Robert A. Bitterman, an emergency physician at the Carolinas Medical Center in Charlotte, N.C., said: "The new rule could aggravate an existing problem. Specialists are not accepting on-call duties as frequently as we would like. As a result, hospital emergency departments lack coverage for various specialties like neurosurgery, orthopedics and ophthalmology. The new rule could make it more difficult for patients to get timely access to those specialists."

Mr. Scully's deputy, Leslie V. Norwalk, said: "The old rules contributed to the overcrowding of emergency rooms. Hospitals were afraid to move patients out of the emergency department for fear of violating the rules."

The new rule, while not a wholesale return to the situation before 1986, scales back regulations that specify when and where hospitals have to provide emergency services. Patients turned away or refused emergency care can still sue, but hospitals will, in many cases, have stronger defenses.

Dr. Douglas L. Wood, a cardiologist at the Mayo Clinic in Rochester, Minn., said hospital duties under the 1986 law had grown because of court decisions and the "layering of regulation on regulation."

In the last five years, the government has collected more than $4 million from 164 hospitals and doctors accused of violating the law.

The new rule narrows the definition of "hospital property" where patients are entitled to emergency care. In addition, it says the 1986 law does not apply to emergency patients after a hospital has admitted them.

The 1986 law, the Emergency Medical Treatment and Labor Act, or Emtala, applies to all hospitals that participate in Medicare and offer emergency services.

Under the law, if any person-not just a Medicare beneficiary-goes to the emergency department of a hospital for treatment, the hospital has to provide a "medical screening examination."

If the examination shows an emergency medical condition, the hospital has to provide treatment to stabilize the patient's condition. Alternatively, the hospital can have the patient transferred to another institution if the expected benefits outweigh the risks.

Under the new rule, the administration says, "Emtala no longer applies to any individual who is admitted as an inpatient."

Hospitals and doctors who violate a requirement of the 1986 law can be fined $50,000 for each violation and can be excluded from Medicare. In addition, patients have a right to sue hospitals that violate the law. Some patients have recovered hundreds of thousands of dollars.

The American Hospital Association and other industry groups have long sought changes in the emergency room standards. In 1999, when Mr. Scully was president of the Federation of American Hospitals, he complained that the government was using the 1986 law in ways never intended by Congress.

Maureen D. Mudron, Washington counsel for the American Hospital Association, welcomed the new rule today, saying that it provided "clear and practical guidance."

Under federal law, each hospital participating in Medicare also has to keep a list of doctors who are available, on call, to treat emergency room patients.

The new rule gives hospitals greater discretion in arranging such coverage. A hospital can legally exempt senior members of the medical staff from on-call duty, it says. Moreover, the new rule says federal law does not require all hospitals to have doctors on call 24 hours a day seven days a week.

In addition, the rule says, doctors can have simultaneous on-call duties at two or more hospitals and can schedule elective surgery or other medical procedures when they are on call.

The old rules applied to all hospital departments, even those not at the main hospital site. The new rule applies to an "off-campus" site only if it is specifically licensed as an emergency room, if the site is held out to the public as a place that provides emergency care or if emergency cases accounted for at least one-third of all outpatient visits in the prior year.

The old rules provided protection to anyone seeking care on hospital property, meaning "the entire main hospital campus."

The new rule makes clear that the law does not apply to doctors' offices, rural health clinics, nursing homes or other "nonhospital entities," even if they are adjacent to the main hospital building and are owned or operated by the hospital.


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U.S. Eases Rules on Requirements for Hospital Emergency Care

California's stricter law means the changes shouldn't affect patients here, providers say.

By Vicki Kemper and Tracy Weber

Times Staff Writers

September 4, 2003

WASHINGTON-The Bush administration has revised federal rules requiring hospitals to provide emergency medical care, easing some regulations about screening, providing specialists and transferring patients.

In California, the changes are unlikely to affect how emergency-room patients are treated, hospital officials said Wednesday, because the state's stricter law remains in effect.

"We will continue to do what we've been doing all along-providing complete screening and stabilization" of emergency-room patients, said Jim Lott, spokesman for the Hospital Assn. of Southern California. "I don't see anything happening that will endanger anyone in California."

But some emergency-room doctors at county-run hospitals in Los Angeles said they feared the new regulations would eliminate any incentives for private hospitals to provide specialists to care for the uninsured.

The new regulations amend the 1986 Emergency Medical Treatment and Labor Act.

That law requires any hospital participating in the Medicare program to provide appropriate medical screening for all patients seeking care in an emergency room or department, regardless of their ability to pay.

Hospital personnel must stabilize the condition of any patient determined to have a medical emergency or transfer the patient to another medical facility.

Hospitals can be suspended from Medicare and fined $50,000 each time they violate the law, which also gives patients denied emergency care the right to sue hospitals.

Other provisions require hospitals to make specialty physicians available around the clock for emergency care and to ensure that all hospital-owned treatment facilities, such as radiology clinics, laboratories and specialty hospitals, are capable of providing emergency care.

The administration's changes relax those requirements, letting hospitals "share" on-call specialists and allowing specialty hospitals and outpatient clinics to transfer emergency patients to emergency departments, including those owned and operated by other hospitals.

Bush administration officials said Wednesday that their changes to the law, which the hospital industry had sought for years, simply clarify hospitals' legal responsibilities to emergency-room patients.

"This regulation is going to make it easier for people to get emergency-room care," said Thomas R. Barker, special assistant to the administrator of the Center for Medicare and Medicaid Services.

Hospital emergency departments have become the first place an increasing number of uninsured and underinsured patients turn to for medical care.

The American College of Emergency Physicians said the change allowing hospitals to share on-call specialists could backfire, resulting in a flood of emergency patients transferred to the declining number of hospitals that will choose to offer specialty care.

"It's going to be unfortunate for most of the county hospitals and the big academic institutions," which have to have such specialists on call, said Dr. Edward Newton, interim chairman of the emergency department at Los Angeles County-USC Medical Center.

Dr. Jack Lewin, chief executive of the California Medical Assn., said the changes to the regulations were overdue and would not result in worse care for the poor.

"We were in an either-or dilemma," he said. "Either we close the emergency rooms in those hospitals or use better coordination."

The American Hospital Assn. welcomed the new rule.

"It recognizes that in emergency departments, hospitals are seeing emergency patients and patients who do not have emergency needs," said Washington counsel Maureen Mudron.

But the California Nurses Assn. "condemned" the new rules.

"This policy could sign a death warrant for an unknown number of people, and aggravate pain and suffering for many others," said association President Kay McVay.

"It may provide a boon for the funeral industry, but it will be a disaster for everyone else."

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