Sunday, May 02, 2004

Good review from this month's Bulletin of the American College of Surgeons. The review is well written and provides a summary of EMTALA's origins and the new regulations. Most of the article deals with the new policy concerning call coverage for hospitals. Essentially it allows hospitals to set up their call rosters "in a manner that best meets the needs of the hospital's patients in accordance with the capability of the hospital, including the availability of on-call physicians.”. There is now approval for such things as covering more than one hospital and performing elective surgery while on call, things that went on before the regulations were changed.
The regulations deal with the "I'm not credentialed for that!!" dodge:

Many physicians limit their scope of practice to well-defined subspecialty areas, even though they are often credentialed by their hospitals to perform all surgery for the broader specialty for which they are board-certified.” For example, a neurosurgeon with limited privileges for spine surgery would argue that he or she is not required to take call for head trauma. Surgeons should be aware that CMS addresses this issue in the current regulations, and hospitals may soon begin to move toward defining core privileges for a number of specialties. CMS states that “a physician who is in a narrow specialty may, in fact, be medically competent in his or her general specialty, and in particular may be able to promptly contribute to the individual's care by bringing to bear skills and expertise that are not available to the emergency physician or other qualified medical personnel at the hospital

But several problems remain....

While the federal government has come a long way in addressing the concerns of the medical community regarding the scope of EMTALA, a number of issues remain that will continue to affect access to emergency surgical care. These issues include: managed care reimbursement policies and emergency room overcrowding; proliferation of single-specialty hospitals; lack of liability protections for EMTALA-related services; and growing burdens on trauma centers and community hospitals.

One such pressure revolves around patients’ inability to receive timely access to specialty care in the nonhospital setting. More often than not, managed care plan enrollees, some of whom are knowledgeable about EMTALA requirements, may use the emergency room when they cannot get an appointment with their regular specialist or primary care physician..... This kind of nonemergent saturation of emergency room departments across the country, particularly in urban areas, is resulting in numerous injured patients being unnecessarily diverted—causing critical delays for individuals requiring acute care.

I can imagine where a savvy managed care patient could use such a situation to do an "end run" around the requirements of their managed care plan. But that's not the worst of it IMHO:

Furthermore, while many physicians are heralding the recent changes in EMTALA’s on-call requirements, others, particularly in the trauma community, are worried that these changes will further exacerbate the financial difficulties facing trauma centers and community hospitals. Under EMTALA, hospitals are now only required to maintain an on-call list “in a manner that best meets the needs of the hospital’s patients in accordance with the capability of the hospital, including the availability of on-call physicians." Many trauma professionals believe that this change in the regulation will provide hospitals, particularly for-profit entities, with the ability to shield themselves from caring for severely injured patients by limiting on-call schedules. For example, some hospitals may only provide on-call coverage until 9:00 pm every night—leaving the local trauma center as the provider of last resort.

This is already happening at some smaller local hospitals, some not-for-profit, and it's not limited only to trauma. This was a major concern brought up during the Trauma and Critical Care meeting in Las Vegas. Unfortunately this is one of those issues that is likely to get worse before it gets better.

Read the whole thing.
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