Published in the February 2014 issue of Today’s Hospitalist
“We got another dump from Middleclass General Hospital “guy with pneumonia arrived by private vehicle, probably should go to ICU.”
“Sure, doc, we have hyperbaric oxygen. But our transfer center’s going to want a wallet biopsy on this guy before they accept him.”
As a resident at a county hospital in the 1980s, I heard statements like this all the time. Patients without insurance were subject to all kinds of substandard treatment: Women in labor had their babies in ambulances en route from private hospitals to public ones, transfers were made before patients were even partially stabilized, and some hospitals accepted transfers for “higher level of care” only if the patients had a way to pay for it. The “wallet biopsy” “a valid insurance card “was a requirement for admission to many inpatient facilities.
In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), and things changed overnight. Patients who came to a hospital’s emergency facility had to have medical screening examinations and be stabilized as much as possible before any transfer. Further, patients had to be informed of the risks of transfer, and there had to be a medical reason for it.
All possible records and consent forms had to be sent to the accepting institution. And refusal to accept a patient based on financial status became grounds for fines or loss of participation in federal programs like Medicare.
Where hospitalists enter this picture
“Who’s on call for GI tonight?” you ask the ER doctor. You are admitting a walk-in patient with an obvious upper GI bleed, and even with aggressive fluid management in the ICU, his blood pressure is barely above shock levels.
But Dr. Gastro can sense through the phone line that this is an uninsured alcoholic with cirrhosis, and he tells you he won’t come in for the very urgent endoscopy. In this case, you can file “or threaten to file “a complaint with the Centers for Medicare and Medicaid Services (CMS), regardless of whether any government coverage is involved.
Penalties for failure to assist with an emergency problem while on call at a hospital can involve anything from fines to exclusion from the Medicare program. The hospital may also be fined if the on-call specialist is seen as an agent of the hospital. (And yes, those who report violations are protected by a “whistleblower” clause.)
Other unacceptable reasons to refuse to see a patient include: “I fired that ** six months ago,” “He might need an ERCP and I don’t do those” or “I’ll see her after you transfer her to my usual hospital.” A request to transfer a patient elsewhere is acceptable only if the other hospital has facilities the patient needs and your hospital lacks.
The take-home message is that if the doctor at the bedside thinks the specialist needs to come in, it is an EMTALA violation if the specialist refuses “unless that specialist has a valid medical reason not to do so. This applies to you too if the ER doctor asks you to appear personally instead of phoning in orders.
“He needs to go to Academia General”
EMTALA also supports you when you need to transfer a patient to another hospital. Even a very good general hospital may lack super-specialists who do transcatheter heart valve replacements or the equipment to provide last-ditch treatment for respiratory failure.
So you start making phone calls “but you can’t just rattle off the catchphrase “higher level of care.” Instead, you have to be able to explain what your patient needs and why it has to be provided urgently, and you need a comprehensive list of medical problems and necessary procedures ready to tell the receiving doctor. Be sure to document his or her name in the chart along with a summary of the conversation.
While you may try to grease the wheels by volunteering the fact that your patient is heavily insured, the receiving institution is not allowed to ask about insurance coverage. And if an insurer requires preauthorization for a procedure, that process may not be used to delay emergency treatment.
Back to the uncooperative specialist: If threats of federal consequences fail to bring in the help your patient needs, you may need to transfer him elsewhere (the patient, not the specialist). And the receiving hospital may not decline the transfer because of your specialist’s refusal to see him.
Finishing the paperwork
As transportation is called, somebody will put a variety of forms in front of you. These include a certification of transfer, a listing of risks and benefits discussed with the patient or surrogate, and the records from the patient’s time with you.
Filling these in fulfills your legal requirements. But feel free to add a short note yourself or dictate a stat discharge summary and have it printed out to go on the top of the pile.
Similar communication is required when you transfer a patient to a “step-down” unit like long-term acute care or skilled nursing, although that communication can be in writing rather than via a phone call. We are fortunate to have nurses and secretaries who take care of copying the chart and notifying the receiving doctor. All that information is still mandatory, so please appreciate these people.
Let’s not start a fight
EMTALA also gives you a way to avoid conflict and complaints about your “attitude.” If a colleague isn’t following the rules, you can be ever so polite and sympathetic “”but gosh darn it, those government regulations just won’t let me be as nice to you as I want to be.” Add in that you’re trying to prevent the good doctor from having to put up with inquiries, fines and administrative hassles, and you’ll be seen as part of the solution.
Stella Fitzgibbons, MD, has been in practice since 1984 and has been both a hospitalist and an ER doctor. She also provides expert-witness assistance in malpractice cases.
Still have questions?
You’ll find that www.emtala.com has a very comprehensive “FAQ” list with clear answers. If you need to get in some ethics credits, www.vlh.com has a $100 online course on EMTALA with 4 CME credits. And www.medlaw.com is a good place to go for articles and explanations regarding this and other medicolegal concerns.