"GOVERNMENT & MEDICINE
New set of EMTALA guidelines addresses on-call concerns
Government memorandums approve simultaneous call and elective surgery.
By Markian Hawryluk, AMNews staff. July 8/15, 2002. Additional
information
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Washington -- When the Centers for Medicare & Medicaid Services in May
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proposed clarifications and modifications to federal statutes
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prohibiting patient "dumping," physicians couldn't help but be a little
disappointed the agency didn't address the on-call provisions. In June,
CMS rectified the situation.
In a pair of program memorandums to regional administrators, the agency
clarified that physicians could be on call for multiple hospital
emergency departments at one time and could perform scheduled surgery
while on call without violating the regulations.
The changes listed in the program memorandums can be implemented by
regional administrators immediately.
Under the Emergency Medical Treatment and Active Labor Act, hospital
emergency departments were required to maintain panels of specialists
who would be on call for emergency services. However, physicians
complained that hospitals' need for continual on-call services put great
pressure on their private practices and forced them to leave regular
patients to see emergency cases.
These factors, as well as shortages of certain specialists, led many
physicians to drop some of their hospital privileges to avoid excessive
on-call responsibilities. But that also left many facilities unable to
secure specialists to serve on the on-call panels.
In many cases, physicians were on call to multiple facilities at the
same time, despite CMS' warnings that simultaneous call violated EMTALA
regulations. In the June program memorandums, CMS reversed that stance.
"After lengthy discussions with the medical community, and understanding
the impact of this policy, CMS is revising its policy to allow on-call
physicians to provide coverage simultaneously at several hospitals to
maximize patient access to care," the CMS memorandum said.
The agency cautioned that the change does not relieve facilities of
their EMTALA obligations. Hospitals must establish policies and
procedures to be followed when a physician of a particular specialty is
not available or if the on-call physician cannot respond, CMS said.
Those policies could include backup on-call physicians or an appropriate
transfer under EMTALA regulations.
The memorandum also said in cases of simultaneous call, each hospital
should know the physician's on-call schedule for all hospitals involved.
In a separate letter, CMS clarified that physicians could perform
surgery while on call, but should find a backup in the event they are
called while performing elective surgery.
"We anticipate that [state] surveyors would recognize that physicians
and hospitals need flexibility in developing a backup plan and that the
backup plan needs to be developed in the best interests of the
community," CMS said.
According to John C. Nelson, MD, a Salt Lake City obstetrician and AMA
secretary-treasurer, EMTALA is an example of a regulation that started
out with good intentions but has since "run amok." The on-call changes
have helped steer the regulations back to their original goal, he said.
"The federal regulation has overstepped the original intent by a long
shot," Dr. Nelson said. "The AMA has worked hard and long to erase
some of the overshoot, if you will, to get it back to the original
intent. And that's what has happened here."
Enough protection?
While physician groups were pleased with the announcement, many
cautioned that the memorandums did not offer the same level of
protection as published regulations.
"Those are strictly guidelines," said Phillip Tally, MD, a neurosurgeon
from Bradenton, Fla. "We should keep this moving until we get it in
stone in the Federal Register. Guidelines, as we all know from our
experiences, are just that, guidelines. We can still be attacked on
that basis."
Neurosurgeons have been especially hard hit by EMTALA on-call
provisions. With fewer neurosurgeons than hospitals in the United
States, neurosurgeons are often on call at four or more hospitals at
once.
Physician concern over EMTALA surfaced at the AMA's Annual Meeting in
Chicago in June. Delegates debated the creation of an EMTALA technical
advisory group that could help direct CMS oversight and modification of
the controversial regulations. The issue was ultimately sent to the
Board of Trustees for study.
The delegates also expressed concern about anti-kickback and
self-referral prohibitions and whether physicians who are being paid for
being on call are in compliance.
"This is an area where attorneys are beginning to raise questions," said
Brian Johnston, MD, emergency physician and board chair for the Los
Angeles County Medical Assn. "In many communities, the ability to pay a
physician for his or her time on call is absolutely critical to
maintaining the on-call panels on which the emergency departments rely."
A wave of attention
The memorandums come on the heels of a number of EMTALA reforms. In
May, CMS recommended numerous EMTALA changes as part of a proposed rule
on Medicare hospital inpatient payments.
With the proposed changes, CMS clarifies that there is no requirement
for continuous on-call services and to dispel the notion that a hospital
must provide continuous on-call services for a specialty if it has
access to three or more of those specialists.
The proposal would also allow facilities to meet managed care
preapproval requirements, limit EMTALA to hospital departments that
routinely provide emergency care, and allow ambulances to follow
community emergency medical service protocols without violating EMTALA.
Those potential changes reflect recommendations by the Advisory
Committee on Regulatory Reform, established by Health and Human Services
Secretary Tommy Thompson. However, the proposal is part of a
rule-making process. The comment period was set to expire on July 8, at
which point HHS can make the rule final.
Back to top.
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ADDITIONAL INFORMATION:
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Easing EMTALA
The Centers for Medicare & Medicaid Services issued changes to the
Emergency Medical Treatment and Active Labor Act rules aimed at easing
their burden on physicians and hospitals.
June, CMS program memorandum
Simultaneous call at multiple hospitals permitted.
Physicians may perform elective surgery while on call.
May, CMS proposed rule
No requirement for continuous on-call services.
Facilities can meet managed care preapproval requirements as long as
this does not delay screening and stabilization services.
EMTALA limited to hospital departments that routinely provide emergency
care.
EMTALA obligations end once a screening has determined there is no
emergency. OJO: Porque en el Ashford se ha hecho tan dificil entender
eso?????
EMTALA applies to inpatients only under limited circumstances.
Ambulances may follow community emergency protocols without violating
EMTALA"
At Mon, 8 Jul 2002, Braun, R. Daniel wrote:
>
>She would be admitted and delivered. (At the vast majority) To do
>otherwise is illegal and opens one to a $25000 fine without appeal.
>Dan
>
>-----Original Message-----
>From: freda [mailto:fredamw@ca.inter.net]
>Sent: Monday, July 08, 2002 11:23 AM
>To: Multiple recipients of list OB-GYN-L
>Subject: American hospital procedure
>
>What would happen if a woman arrived at an American hospital if she
>arrived at the hospital in labour with no insurance or money?
>
> What about if she just had medicaid?
>
>--
>Freda Seddon, RN, RM
>Community Midwife
>37 Chelwood Rd., Toronto,
>Ontario M1K 2K5
>(416) 750-3100 fax 757-1562
>
--
"Life is neither the notes nor the silence between the notes, but the music that
arises out of sound and silence felt as a living whole. Stop choosing...between
chaos and order, and live at the boundary between them, where rest and action
move together..." David Whyte
