BANKRUPTCY,MEDICAL INSURANCE,AND A LAW WITH UNINTENDED CONSEQUENCES

Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, guaranteeing a standard of medical care to anyone who entered an emergency room. This guarantee made default a more reliable substitute for medical insurance. I construct a tractable structural model of the medical insurance market and find that repealing EMTALA would increase the fraction of the population with insurance while decreasing its price. Copyright © 2013 John Wiley & Sons, Ltd.     

Summary of final changes to EMTALA regulations

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1986. Its purpose was to ensure that all individuals receive necessary emergency services from hospitals and not be denied care (i.e., "patient dumping") because of their economic status or lack of insurance. In its application, EMTALA has reduced "patient dumping," but at great cost to hospitals and physicians as an unfunded mandate. Despite 17 years of experience with the law, providers have been uncertain as to where and when, and to whom, the EMTALA obligations apply. The law has also proven to be burdensome and has been interpreted as extending far beyond the hospital emergency room. After reviewing the law for some time, the Centers for Medicare and Medicaid Services (CMS) released its final rules redefining the scope of EMTALA, reaffirming certain guidelines and modifying or clarifying others. The new regulations attempt to restate the parameters of the law as it applies to the emergency department and the hospital, as well as to inpatients and outpatients. The new rules clarify on-call obligations for physicians, confirming guidance issued by CMS in June 2002. This article summarizes the salient features of these new regulations.     

Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare‐participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted 11 semistructured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested 5 methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA‐compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest (1) more closely aligning Medicaid/Medicare payment policies with EMTALA, ( 2) amending the Act to permit informal mediation between hospitals about borderline violations, (3) increasing the hospital's role in ensuring EMTALA compliance, and (4) expanding the role of hospital associations.     

Cops and docs: The challenges for ED physicians balancing the police,state laws,and EMTALA

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers.     

Learning the developments in EMTALA jurisprudence through the lens of John West's “case law update”

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an “appropriate” medical screening examination; second, when is a patient actually “stabilized’ under EMTALA; and third, does the EMTALA obligation really “disappear” when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to “get it right” on the law and that drive risk managers crazy. EMTALA is the “poster child” for such a topic.     

Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

The Emergency Medical Treatment and Labor Act (EMTALA)

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted to prevent patient dumping. It provides patients a considerable amount of protection and leverage in obtaining care under emergency situations. The reimbursement strictures imposed by managed care organizations have compounded the problems. This article summarizes the Act's definition of role and duties of hospitals and physicians and the regulations to which these parties must adhere or face significant penalties.     

A Better Idea for United States Health Care - The Balanced Choice Proposal

This article introduces a promising new health care financing proposal for physician payment called Balanced Choice. It summarizes the implications of health care economics and current well-publicized health care reform proposals, each of which is problematic for physicians and their patients. The Balanced Choice proposal is for an integrated two-tier national system, which has an economically efficient universal plan similar to single-payer, but with an option for enhanced services using market forces at the doctor-patient level to manage care. The two tiers are linked together and balanced so that each complements and enhances the other. Balanced Choice solves the problems of other proposals in a way that would work well for doctors and for patients, and represents a fresh and uniquely American solution to the problem of health care financing.The health care reform proposal recently passed by Congress maintains the inefficiencies and perverse incentives of an insurance model that rewards denial of care and imposes intolerable administrative burdens on the practice of medicine. A new universal proposal called Balanced Choice offers economic efficiency, administrative simplicity, and returns care management and control of fees to doctors and patients. To explain, we need to start with a review of basic health economics.     

Denial of impending death: a discourse analysis of the palliative care literature

Terminally ill patients and their families are often referred to as being "in denial" of impending death. This study uses the qualitative method of discourse analysis to investigate the usage of the term "denial" in the contemporary hospice and palliative care literature. A Medline search (1970-2001) was performed combining the text words "deny" and "denial" with the subject headings "terminal care", "palliative care" and "hospice care," and restricted to English articles discussing death denial in adults. The 30 articles were analysed using a constant comparison technique and emerging themes regarding the meaning and usage of the words "deny" and "denial" identified. This paper focusses on the theme of denial as an individual psychological process. Three dominant subthemes were distinguished: denial as an unconscious "defence mechanism", denial as "healthy" and denial as temporary. The analysis focusses on the intertextuality of these themes with each other and with previous texts on the denial of death. Elements of the psychoanalytic definition of denial as an unconscious defence mechanism are retained in the literature but are interwoven with new themes on patient choice. The result is an overall discourse that is conflictual and at times self-contradictory but overall consistent with the biomedical model of illness. I suggest that the representation of death denial elaborated in these articles may be related to a larger discourse on dying in contemporary Western society, which both invites patients to participate in the planning of their death and labels those who do not comply.     

Liability for managed care decisions: the Employee Retirement Income Security Act (ERISA) and the uneven playing field.

As managed care organizations expand their programs of quality assurance and physician evaluation, more medical malpractice lawsuits may be brought against managed care organizations on the ground that, like hospitals, they are legally responsible for negligent corporate acts that injure patients. However, the federal Employee Retirement Income Security Act (ERISA) shields managed care organizations from liability when they are part of an employee group health plan governed by ERISA. Unlike patients with other types of insurance, patients in ERISA health plans do not have a malpractice remedy for a managed care organization's negligence. A few federal appeals courts recently recognized that ERISA plans can be vicariously liable for their physicians' medical malpractice, but only if the physician is the plan's employee or agent. Yet ERISA still prohibits negligence claims against ERISA health plans for injuries resulting from denial of plan benefits, failure to use qualified physicians, utilization review, or improper plan administration. Current managed care operations do not neatly distinguish between administering benefits and controlling quality of care. Neither should the law. ERISA should be amended to provide employees with the same remedies that patients in non-ERISA plans enjoy.     

Myocardial infarction and denial

Denial, a natural defense mechanism, can be either an appropriate or an inappropriate response to anginal pain. Myocardial infarction sufferers often delay several hours before seeking medical attention, and most deaths from infarction occur before hospitalization. These two facts indicate that denial may contribute to mortality from coronary artery disease. To encourage "stoical" patients to seek medical care, nonthreatening educational approaches to cardiac disease and concentrated efforts to reduce anxiety toward hospitals are needed. Family physicians knowledgeable about the effects of denial can screen cardiac-prone patients for inappropriate denial and alter diagnostic approaches in an attempt to lessen the role denial plays in cardiac deaths.     

EMTALA obligations for psychiatric patients

The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 and governs the obligations of licensed hospitals that participate in the Medicare program with respect to patients with emergency medical conditions. Psychiatric units and facilities often believe that it does not apply to them, or they are cavalier in their efforts to comply with it. If the entity is a licensed hospital, or operates within a licensed hospital, that participates in Medicare, the Act is fully applicable to them. Such entities disregard EMTALA at their peril.     

Court decisions side with continued treatment of medically futile cases

Confusion reigns in the care of two medically futile cases as one state's supreme court requires hospitals to ask the local state attorney's office to arbitrate conflicts between "acceptable medical treatment and the patient's wishes," and another court applies the federal Emergency Medical Treatment and Active Labor Act (EMTALA) to require a hospital to stabilize an anencephalic child's respiratory distress.     

Denial and its association with mental health care use

In clinical practice, denial has long been thought to be a determinant of treatment initiation and retention; however, little empirical research has focused on denial as a mechanism. For example, denial has not been standardized or operationalized in epidemiological studies for mental health services research and, thus, the magnitude of the effects of denial on mental health care use are unknown. This study makes use of the "Mental Health Care among Puerto Ricans" study, a 3-wave island-based probability epidemiological study conducted from 1992 to 1998. For all the 3 waves, 2928 individuals participated (81.5% response). The analyses were limited to only those participants who were objectively determined to have a severe need for mental health care (n = 742). The findings from this study show that admitting to a mental health problem is related to the increased odds of using any mental health care, any specialty care, psychotropic drugs, and retention in mental health care, after adjusting for potential confounding. Similar patterns were observed even after the data were limited to those participants who did not previously seek mental health care, and the trends persisted when determining changes from denial to admitting a mental health problem. The study confirms that denial is a significant factor for treatment initiation and retention, particularly for Puerto Ricans, and denial should be considered an important mechanism in planning interventions to eliminate mental health care disparities.     

"That's not my fault!"

Employees may use denial as a way to cope with underperformance. When denial is used in the health care environment by employees, it often presents the supervisor with a situation requiring intervention. This article describes the dynamics of denial and strategies for the supervisor for responding to denial in the workplace.     

Controlling workers' compensation medical care use and costs through utilization management.

Little is known about the performance of utilization management (UM) programs, which are now widely used within the workers' compensation system to contain medical costs and improve quality. UM programs focus largely on hospital care and rely on preadmission and concurrent reviews to authorize hospital admissions and continued stays. We obtained data from a large UM program representing a national sample of 9319 workers' compensation patients whose medical care was reviewed between 1991 and 1993. We analyzed these data to determine the denial rate for hospital admission and outpatient surgery and the frequency of length-of-stay restrictions among hospitalized patients. The denial rate was approximately 2% to 3% overall, but many of the denials were later reversed. On average, the UM program reduced the length of stay by 1.9 days relative to the number of days of care requested. The estimated gross cost savings resulting from reduced hospitalization time and decreased outpatient care was approximately $5 million. UM programs may offer a viable approach to cost containment within the workers' compensation system. Their value as a tool to improve the quality of care for workers' compensation patients remains to be demonstrated.     

Death denial: obstacle or instrument for palliative care? An analysis of clinical literature

As a society and as individuals, we have come to recognize ourselves as 'death-denying', a self-characterisation particularly prominent in palliative care discourse and practice. As part of a larger project examining death attitudes in the palliative care setting, a Medline search (1971 to 2001) was performed combining the text words 'deny' and 'denial' with the subject headings 'terminal care', 'palliative care' and 'hospice care'. The 30 articles were analysed using a constant comparison technique and emerging themes regarding the meaning and usage of the words deny and denial were identified. This paper examines the theme of denial as an obstacle to palliative care. In the articles, denial was described as an impediment to open discussion of dying, dying at home, stopping 'futile' treatments, advance care planning and control of symptoms. I suggest that these components of care together constitute what has come to be perceived as a correct 'way to die'. Indeed, the very conceptualisation of denial as an obstacle to these components of care has been integral to building and sustaining the 'way to die' itself. The personal struggle with mortality has become an important instrument in the public problem of managing the dying process.     

Data field standards and the Health Insurance Portability and Accountability Act

The Administrative Simplification Title of the Health Insurance Portability and Accountability Act of 1996 addresses the creation and adoption of nationwide standards for the electronic exchange and confidentiality protection of all individually identified data used in health care administration. The U.S. Department of Health and Human Services (DHHS) is implementing standards under this law. In addition to new standards, the law mandates that the Congress pass a health information privacy bill by August 1999 or that the DHHS adopt privacy protections for health information by February 2000. Published in 2001 by John Wiley & Sons, Ltd.     

Internal and external barriers to obtaining prenatal care

Few studies have examined the reasons women do not obtain medical care during their pregnancies. A retrospective case review of 70 patients in a large metropolitan hospital who received minimal prenatal care examined demographic variables and reasons women gave for not seeking care. Data suggested there are both internal and external barriers to care. More women cited reasons including depression, denial, and fear than cited financial or transportation problems. Implications for social work intervention in the hospital and in the community are drawn from the data and discussed.     

Maternal minimum-stay legislation: cost and policy implications.

OBJECTIVES: Recently, most state legislatures and Congress have passed laws mandating insurance coverage for a minimum period of inpatient care following delivery. This study analyzed the likely cost implications of one state's law. METHODS: Hospital discharge records for Illinois women who gave birth (n = 167,769) and infants born (n = 164,905) during a 12-month period predating the law were analyzed. RESULTS: As a percentage of total spending on birth-related admissions and readmissions, the net effect of the law ranges from a savings of 0.1% to a cost of 20.2%. CONCLUSIONS: There may be large cost implications to this legislation, even with savings from avoided re-admissions.