ER Rules May Curtail Crucial Care

The Bush administration is rewriting federal rules to narrow the emergency care that hospitals must provide even to patients who cannot pay, a newspaper reports.

The changes, which will be published in next Tuesday's Federal Register and take effect Nov. 10, put limits on a 1986 law that applied to all hospitals that participate in Medicare and provide emergency services. The new policy will make it harder for patients to win lawsuits based on the 1986 law.

According to The New York Times, the changes have been sought for years by hospitals arguing that the 1986 rules — broadened by litigation — imposed unreasonable costs.

"The overall effect of this final rule will be to reduce the compliance burden for hospitals and physicians," says the announcement to be printed next week in the Federal Register.

But some doctors say the new policy will restrict patients' access to crucial care, The Times reports.

The 1986 Emergency Medical Treatment and Labor Act, or Emtala, required that:

• hospitals provide an emergency medical screening to anyone that came into the emergency room. If the screening showed an emergency medical condition, the hospital had to treat it or transfer the patient to an institution where the condition could be treated better.
• hospitals keep a list of specialists on call to treat emergency medical conditions.
• hospitals apply the rules not only to their emergency rooms, but also to other clinics and offices it owned.

The government has netted $4 million in fines from 164 providers in the past five years. That's less than a tenth of a percent of the total benefits paid out by Medicare over the past five years to hospitals, nursing homes and doctors.

Patients can also sue over violations, and some have collected large cash awards.

The administration's new policy would make the 1986 law apply only until the hospital admitted a person as an inpatient. In addition, the law will apply only at facilities licensed or depicted as emergency care facilities, says The Times.

Hospitals will also be able to exempt senior staff from on-call lists and won't be required to maintain the on-call coverage every hour of every day, while doctors will be allowed to be "on-call" at more than one hospital at a time, the newspaper reports.

Thomas A. Scully, head of the federal agency that runs Medicare and Medicaid, told The Times the 1986 law did "a lot of wonderful things, but also does some perverse things that cause a lot of heartburn for doctors and hospitals."

He said the law forced hospitals to give emergency medical training to staff who worked in non-emergency offices off hospital ground. Critics of the 1986 law also blame it for crowding emergency rooms because doctors are worried that moving patients may violate the law.

Scully said the new rules would cut costs without hurting patient care.

At least one doctor disagreed.

"The new rule could aggravate an existing problem. Specialists are not accepting on-call duties as frequently as we would like. As a result, hospital emergency departments lack coverage for various specialties like neurosurgery, orthopedics and ophthalmology," Dr. Robert A. Bitterman, an emergency physician at the Carolinas Medical Center in Charlotte, N.C., said.

"The new rule could make it more difficult for patients to get timely access to those specialists," he said.