ACA Timeline: Key Dates for Providers and Patients

Nurses Activism

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Specializes in Vents, Telemetry, Home Care, Home infusion.
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Specializes in FNP, ONP.

My state has welcomed the ACA. Open enrollment is going to be interesting and we are counting down! My company estimates we will get as many as 18,000 new primary care patients. Medicaid reimbursement is reasonable here, and they pay promptly 100% of the time, keeping collections up. We are going to need trucks to haul the tons of money we are going to rake in, patients are going to be taken care of in a far more cost effective way than the ED. All of us are opening up our panels to prepare. I'm reserving 4 appointment slots a day strictly for new ACA patients, in addition to my 4 frozen slots for emergencies, which will likely end up being ACAs if none of my other patients needs a last minute appt. That's 1/3 of my patient day! Most of my colleagues are doing something similar.

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I'm hoping the implementation of ACA results in fewer primary care patients in the ED; we've got enough serious stuff to keep us going.

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I'm hoping the implementation of ACA results in fewer primary care patients in the ED; we've got enough serious stuff to keep us going.

I think it might require more than just rolling out the ACA to really cut the number of primary care visits to the ED unfortunately. Most importantly you have to convince people to actually use a primary care provider (insurance or not). I have not worked in EMS for years, but when I did I saw just as many people abuse the system who had insurance, and a primary care provider, as I did those who did not. It is somewhat a cultural issue I think. I still know people who believe the ED doctors are somehow "better" than a primary care provider even when it comes to treating things which can be successfully treated in a primary care provider's office. Nor is this phenomenon limited to just here in the US. I have a friend who lives in London and works for the NHS. He told me that even though they do not have to pay to see their General Practitioner they still have people show up at the A&E (what we would call ED) to be seen for things that should be being handled in their GPs office (and they are required to establish a medical home at a GPs office). So, like I say, I think it will take a very large educational push to convince people to use the ED for ED type things and primary care for primary care type things. I am sure that the ED you work in tries their hardest, same as most, to do that education now. So, I don't think people have not been trying to educate patients I just think it might take a large education push (maybe Johnson and Johnson can hold off on pushing nursing school for a while and use their education dollars to educate about the "real" use of an ED or something?).

Anyway, just wanted to throw my two cents in there.

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I think it might require more than just rolling out the ACA to really cut the number of primary care visits to the ED unfortunately. Most importantly you have to convince people to actually use a primary care provider (insurance or not). I have not worked in EMS for years, but when I did I saw just as many people abuse the system who had insurance, and a primary care provider, as I did those who did not. It is somewhat a cultural issue I think. I still know people who believe the ED doctors are somehow "better" than a primary care provider even when it comes to treating things which can be successfully treated in a primary care provider's office. Nor is this phenomenon limited to just here in the US. I have a friend who lives in London and works for the NHS. He told me that even though they do not have to pay to see their General Practitioner they still have people show up at the A&E (what we would call ED) to be seen for things that should be being handled in their GPs office (and they are required to establish a medical home at a GPs office). So, like I say, I think it will take a very large educational push to convince people to use the ED for ED type things and primary care for primary care type things. I am sure that the ED you work in tries their hardest, same as most, to do that education now. So, I don't think people have not been trying to educate patients I just think it might take a large education push (maybe Johnson and Johnson can hold off on pushing nursing school for a while and use their education dollars to educate about the "real" use of an ED or something?).

Anyway, just wanted to throw my two cents in there.

I'm hoping that part of the cultural shift, and the changes in reimbursement, will lead the ED docs to start saying, "Oh, this is not an emergency... you need to see your regular doc." The wait times alone at our facility should drive a number of them away.
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Specializes in Nephrology, Cardiology, ER, ICU.

Well. Lets see...here in IL our last two governors ended up in jail, many of our independent pharmacies have gone under and our Medicaid payments are 2 years behind!!!!

Hmmm. Probably not so hot for my state.

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I'm hoping that part of the cultural shift and the changes in reimbursement, will lead the ED docs to start saying, "Oh, this is not an emergency... you need to see your regular doc." The wait times alone at our facility should drive a number of them away.[/quote']

There is a double problem with this scenario that will probably keep it from being implemented in this manner.

1) Once the doctor has seen the patient they have established a doctor patient relationship. Therefore, regardless of whether or not the patient "needs" emergency care to deny to provide care could be considered abandonment. As I understand law the most they could do is what they are probably already doing now. That is treat the patient, advise them (or have the nurse advise them during discharge instructions) to follow up with their primary care provider, and encourage them to obtain and make use of a primary care provider if they do not have one.

2) If the doctor decided to allow the triage process to decide who does and does not see a provider in the ED (physician, PA, NP, etc.) then this opens a major liability for the facility as a whole. We live, like it or not, in a lawsuit happy society. And, as you are aware, patient's conditions can and do change. Therefore, it would not be too hard to envision a person showing up in the ED who, at that very point in time, does not "need" emergency care, being triaged as such and sent out of the ED. Later this patient's condition changes which leads to a more costly treatment or long term disability and, after finding an attorney, they file a successful lawsuit against the hospital for withholding of care. In addition, since this type of "triage out the door" approach would have to be approved by the Medical Director for the ED the attorney could also file formal procedures against the license of the Medical Director for causing harm to a patient with a standing order he/she issued.

So, call me a pessimist if you want, but I do not forsee any physicians, at least those adverse to lawsuit or loss of license, telling a patient "this is not an emergency . . . go see your regular doctor" and then withholding any additional care.

As always my two cents worth . . .

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Specializes in FNP, ONP.
There is a double problem with this scenario that will probably keep it from being implemented in this manner.

1) Once the doctor has seen the patient they have established a doctor patient relationship. Therefore, regardless of whether or not the patient "needs" emergency care to deny to provide care could be considered abandonment. As I understand law the most they could do is what they are probably already doing now. That is treat the patient, advise them (or have the nurse advise them during discharge instructions) to follow up with their primary care provider, and encourage them to obtain and make use of a primary care provider if they do not have one.

2) If the doctor decided to allow the triage process to decide who does and does not see a provider in the ED (physician, PA, NP, etc.) then this opens a major liability for the facility as a whole. We live, like it or not, in a lawsuit happy society. And, as you are aware, patient's conditions can and do change. Therefore, it would not be too hard to envision a person showing up in the ED who, at that very point in time, does not "need" emergency care, being triaged as such and sent out of the ED. Later this patient's condition changes which leads to a more costly treatment or long term disability and, after finding an attorney, they file a successful lawsuit against the hospital for withholding of care. In addition, since this type of "triage out the door" approach would have to be approved by the Medical Director for the ED the attorney could also file formal procedures against the license of the Medical Director for causing harm to a patient with a standing order he/she issued.

So, call me a pessimist if you want, but I do not forsee any physicians, at least those adverse to lawsuit or loss of license, telling a patient "this is not an emergency . . . go see your regular doctor" and then withholding any additional care.

As always my two cents worth . . .

It happens here all the time. EDs routinely refuse to treat any chronic issues at all naturally (as well they should) and for about the past year they wont treat non-emergent acute issues either. For example, they do not treat UTIs, AOM, tell the patient "this is not an emergency, go to minute clinic, urgent care or to your PCP." If the patient says they don't have a PCP and can't afford a visit, the answer is "that's a shame. save your money, go when you can."

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Specializes in FNP, ONP.

I wanted to add, this is the current policy in all three major health systems in this city(1 for profit, 1 not for profit, and one major university), which collectively serve about 1 million people. Everyone here knows if it is NOT an emergency, they will be turned away.

We are all looking forward to full implementation of the ACA, at least until someone comes up with something better.

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It happens here all the time. EDs routinely refuse to treat any chronic issues at all naturally (as well they should) and for about the past year they wont treat non-emergent acute issues either. For example, they do not treat UTIs, AOM, tell the patient "this is not an emergency, go to minute clinic, urgent care or to your PCP." If the patient says they don't have a PCP and can't afford a visit, the answer is "that's a shame. save your money, go when you can."

WOW! Not sure what part of the country you live in, but the area I live in does not have those types of policies.

Discussing this with a family friend who is an attorney he offered the following opinion of this procedure (that I had not been aware of until you responded to my post and asked him). He said that in this case you mention this is most likely, as you state, the hospital policy. This means that the ER physicians are usually not liable for any negative effects that this might cause to a patient since the ER physicians have not usually at this point seen the patient and two the ER physicians are usually independent contractors working in the hospital. What can happen, he said, is that the hospital can get sued, and it is possible, hospital policy or not, that the triage nurse making the decision, if said decision is made by a triage nurse, could be sued also.

The reason? The triage nurse is a staff member of the hospital, so they are carrying out the direct order of the hospital. Therefore, the hospital can get sued for inacting a policy that leads to a detrimental outcome for a patient. So, in other words it is sort of like a "Hold Harmless Agreement". Many people erroneously believe that signing a Hold Harmless Agreement gives away your right to sue. This is not the case. Hold Harmless Agreements only work if it can be shown that the actions that lead to the injury, harm, etc. are actions that any responably competent person in that profession would also do. As you can imagine it is not hard at all to find a professional in almost any field who is competent and would be willing to testify that they would not have done what the other professional did in that case. The same applies here. Since not every hospital ER practices this way, regardless of whether or not it is practiced at all the hospitals in your area, it would not be hard at all for an attorney to find a professional from another hospital who would testify that this was not the way they thought things should run.

Where the problem comes up for nurses is that apparently there have been cases where hospitals have successfully argued in court that the individual nurse did not correctly follow triage protocols. From what I understand this has involved cases where patients were triaged too low, but were eventually seen; however, I can only assume that faced with a lawsuit a hospital might try to use this same tactic on the triage nurse who "triages out the door".

The lawyer friend further posited that most likely the only reason that these facilities had not yet been sued was either 1) the people who were turned away did not have the financial resources to seek legal assistance anymore than they had the resources to seek medical help outside the ER and/or 2) the right litigation attorney just hasn't found the right patient yet.

Either way, I still stand behind my statement that it is not the best policy at least from a legal liability reason (and in the case of the "tough luck" that can be construed as harassment). It is one thing to tell a person to leave, it is another entirely to belittle the situation they find themselves in with a "tough luck" statement.

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I wanted to add, this is the current policy in all three major health systems in this city(1 for profit, 1 not for profit, and one major university), which collectively serve about 1 million people. Everyone here knows if it is NOT an emergency, they will be turned away.

We are all looking forward to full implementation of the ACA, at least until someone comes up with something better.

I am not asking in an attempt to get you to divulge where you work, etc. Rather out of a professional interest alone, would you be willing to state which State these facilities are located in? Your user name might reference the State such as North Carolina if it is refering to Duke, it could reference California if it is refering to the Drum Corps of the same name, or it might not in anyway reference the state at all. Like I say, if you don't feel comfortable answering that is fine. I just have an academic interest in the way issues like this are handled from State to State.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I am curious about this as well for as far as I know....Obama care has not eliminated EMTALA/COBRA act of 1986.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was created out of concern that patients were being denied emergency medical treatment because of their inability to pay. The initial intent of EMTALA was to address the allegation that some hospitals were transferring, discharging, or refusing to treat patients who did not have insurance.EMTALA was signed into law in 1986, as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). The Centers for Medicare and Medicaid (CMS) issued revisions to EMTALA in 2003, which can be found in the Federal Register on September 9, 2003.

EMTALA contains 2 basic requirements:

  • For any person who comes to a hospital emergency department, "the hospital must provide for an appropriate medical screening examination . . . to determine whether or not an emergency medical condition exists" (see 42 USC 1395dd[a]).[3]
  • If the screening examination reveals an emergency medical condition, the hospital must "stabilize the medical condition" before transferring or discharging the patient.

The definitions of "medical screening exam" and "emergency medical condition" are discussed in more detail later in this article.

The authority supporting the statute is the taxing and spending clause of the Constitution. In essence, Congress has the right to demand certain services from vendors receiving federal tax dollars. In the EMTALA statute, obligations are tied to hospitals' participation in Medicare. A hospital could relieve itself entirely of EMTALA obligations by dropping out of the Medicare program; however, Medicare is a major funding source for most nonfederally run hospitals.

EMTALA compliance is regulated by the CMS, a division of the Department of Health and Human Services (HHS). There are significant financial consequences for violating EMTALA rules. A hospital and/or the responsible physician may face individual fines imposed by the government as well as civil damages claims. Additionally, the hospital can be excluded from participating in the Medicare program, which may be financially devastating. It is imperative that ED physicians be fully aware of their obligations under EMTALA regulations.

Within this law there are certain requirements.....obligations required my law.

EMTALA outlines specific obligations for the referring hospital, the treating or transferring physician, and the receiving physician and hospital. The main points are as follows:

Medical screening exam

Any person requesting emergency services, who presents to a facility that provides emergency services, must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency medical condition (EMC) exists.

This request can come from the patient, someone accompanying the patient, a law enforcement officer bringing someone to the ED, or someone walking into the ED requesting a blood pressure check.

If the MSE reveals an emergency medical condition, it is the obligation of the treating hospital to stabilize the patient prior to discharge or transfer.

Persons covered by the "250-yard rule"

In addition to persons who come to the ED requesting treatment, EMTALA rules also apply to any person who presents on the hospital campus and requests or requires emergency services. Known as the "250-yard rule," the hospital campus is defined below[4] :

  • Campus means the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the HCFA regional office, to be part of the provider's campus" (42 CFR 413.65).
  • The "250-yard rule" obligates hospital staff to recognize when a visitor, another employee, or anyone on the hospital campus, is in need of a medical screening examination. This includes, "Anyone whom a layperson would believe, based on the individual's appearance and behavior, that the individual needs examination or treatment."
  • Campus typically includes the parking lot, sidewalks, driveways, and inpatient and outpatient areas.
  • The campus does not include nonmedical businesses such as retail business, private physicians' offices, or other medical entities that have a separate Medicare identity.

Patient transfer

The treating physician may transfer the patient in the following scenarios:

  • The emergency medical condition has been stabilized and the patient requires a higher level of care.
  • The emergency medical condition has not been stabilized, but the treating physician certifies that the benefit of transfer outweighs the risk.
  • The patient or health care proxy requests transfer regardless of whether the emergency medical condition has been stabilized.
  • The on-call physician fails or refuses to appear within a reasonable period of time, and without the services of the on-call physician, the benefit of transfer outweighs the risk.

When transferring, the treating physician must document the name of the accepting individual and facility. The treating physician must also send pertinent documents, imaging studies, and test results relating to the emergency condition to the receiving facility.

The receiving hospital must accept the transfer as long as they have the capacity and space to do so. It is the obligation of the receiving hospital or physician to report any transfer received in violation of EMTALA. The receiving hospital may be penalized for failure to report an EMTALA violation.

The transferring hospital must provide all medical treatment within its capacity, which minimizes the risk to the individual's health. Qualified personnel, with the appropriate medical equipment, must accompany the patient during transfer.

On-call physician duty

Hospitals must maintain an on-call list of physicians "in a manner that best meets the needs of the hospital's patients." Note that there is no requirement under EMTALA for full-time, on-call coverage by all specialties. However, the hospital is required to adopt a plan of action for situations where the needed on-call specialist is unavailable.

On-call physicians may be on call for multiple hospitals simultaneously and may schedule elective procedures during on-call hours.

On-call physicians are required to respond in a reasonable time period to assist in the stabilization of a patient with an emergency medical condition.

The ED physician's judgment should be deferred to by the specialist in situations where the ED physician requests the presence of the specialist, but the specialist does not believe that his presence is necessary.

Fulfillment of EMTALA obligations

EMTALA obligations are fulfilled when the following criteria are met:

  • An appropriate MSE identifies no emergency medical condition.
  • The patient refuses to consent to treatment offered or refuses to consent to transfer offered.
  • The emergency medical condition is stabilized.
  • A patient with an EMC is stabilized, admitted, and develops a new EMC.
  • EMTALA obligations do not apply when an individual who is on the hospital campus for outpatient, nonemergency services develops an emergency medical condition after beginning the outpatient treatment (these situations are covered under CMS's "Conditions of Participation" rules).

Enforcement

EMTALA legislation is enforced by CMS. A hospital that has more than 100 beds may be fined up to $50,000 per violation, and a hospital with fewer than 100 beds may be fined up to $25,000 per violation. Individual physicians may be fined as well, including on-call physicians who fail to appear. On-call physicians who request that an unstable patient be transferred when the risk of transfer outweighs the benefit may also be fined. Ultimately, a hospital may have its Medicare provider agreement revoked in response to EMTALA violation.

If you with to read more about EMTALA....COBRA Laws and EMTALA through medscape.....it requires registration but it is free and an excellent source of information.
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