A hospital administrator is tasked with the day to day running of the hospital (Sharma and Goyal, 2013). This means that the administrator bears responsibility for any breach of law that may occur during the discharge of their duties. The administrator must thus be aware of any legal requirements that relate to the hospital. One of the key laws to be aware of is the Emergency Medical Treatment and Active Labor Act (EMTALA). From a general perspective, the law prevents ‘dumping’ of patients out of emergency departments (Pozgar, 2012).
Dumping essentially means transferring patients to another hospital either because they are unable to pay or treating them would be costly for the hospital (Annas, 1992). EMTALA requires participating hospitals to provide medical care to any patient with an emergency medical condition. The Act defines an emergency medical condition as a condition manifested by symptoms of severity to the extent that failure to accord immediate medical treatment would result to severe consequences to the health and or body of the person (Pozgar, 2012). A pregnant woman having contractions is also regarded as an emergency condition. The Act defines participating hospitals as those that accept payment from the Medicare and Medicaid Services.
With respect to the given scenario, it would be important to note that on call physicians are covered by the Act, thus the hospital may be liable for their actions. Accordingly, it would be my duty to ensure that the hospital is not cited for an EMTALA violation. The first step in addressing the transfer request will be to ascertain whether the hospital has the ability and capacity to handle the situation. If the hospital lacks the ability or capacity or both, the transfer would be denied. Importantly, I would communicate the lack thereof to the ED’s assistant.
If on the other hand the hospital has the capacity and ability, the transfer request would be allowed. It would be a violation of the Act to refuse a transfer if the hospital has the capacity and ability. The next step would then be to determine whether the call indeed relates to an emergency condition under the Act. As a matter of fact, the Act imposes two obligations on the hospital; one, to provide medical screening; and two, to stabilize the condition where it is established that an emergency condition exists (Pozgar, 2012).
Patient screening is very important not only to determine the existence of an emergency condition, but also to avert an EMTALA claim against the hospital. As was determined in Ballachino v. Alders, failure to conduct a proper patient screening would entitle the patient to a claim against the hospital (Pozgar, 2012). Where the screening is done appropriately and the patient is turned down, the hospital would not be in breach of the Act, and thus no claim can be made against it.
The wording of the provisions on the medical screening examination connote that the patient has to be examined in person. This therefore means the physician is supposed to examine the patient and not just rely on the case summary or treatment record from the sending hospital. Consequently, it would be prudent to allow the transfer of the patient so that the physician can determine whether the fracture is indeed an emergency condition. The sentiments of the physician that the situation is not an emergency condition would thus be ignored and the transfer allowed.
The Act also prohibits the delay of medical screening examination thus I would ensure that it is carried out as fast as reasonably practicable in the circumstances. Though the Act does not define delay, the general rule is between 30 and 60 minutes after the patient has arrived. As a matter of fact on call physicians are required to respond to calls on emergency conditions in a timely manner (Pozgar, 2012). Preauthorization processes, if any and other processes that may cause delay in conducting the screening would thus be avoided or overlooked.
Even though a further transfer or referral to the office of the on call physician is allowable under the Act, the transfer or referral should be evaluated in light of the Stark Laws and the Anti-kickback statute. Though the transfer or referral may avert delay in conducting the medical examination screening, the violation of these laws may result to penalties to both the hospital and the administrator.
The Stark laws generally prevent a physician from referring Medicaid and Medicare patients to a facility where the physician, a member of their family, or their relative has financial interest. In such regard, I would ensure that such referral is not induced by the on call physician. The Anti-Kickback statute prohibits the making of such referrals in exchange for some financial gain. The prohibition of such referrals is meant to reduce the costs to Medicaid and Medicare. This is because without the prohibition physicians and other hospital staff may collude to unnecessarily inflate medical expenses, which they then claim from the Medicaid and Medicare. I would thus ensure that I would not profit in any way if the referral is made. Moreover, I would only allow such referral only if waiting for the physician would result to a delay in the screening. Further should the transfer be necessarily, I would ensure it relates only to the activities exempted for Medicare and Medicaid.
Once the medical screening examination is conducted, the patient would be stabilized if an emergency condition exists. If not, I would have the physician indicate so in writing to ensure there is documentation to prove there was no emergency condition. I would also ensure that the screening is standard, that is, the same as any other patient would receive. This is important as a deviation from the standard screening may be a violation of the Act (Pozgar, 2012), which may lead to a claim against the hospital.
The other requirement under EMTALA is stabilization. From a general perspective, stabilized under the Act means that within sensible medical sureness, no material worsening should occur on the patient during or from the transfer (Pozgar, 2012). The 2008 Amendments to the Act broadened the meaning of a stable patient. Ideally, if the patient is out of any danger to their health or body, is conscious and communicating as usual, they are regarded as stable. This obligation is to ensure that the patient is stable, not cured.
Once the patient is stable, they may be discharged or transferred to another facility. The Act requires that the transfer be appropriate, which means that the circumstances permit the transfer. Again if a transfer to another facility is necessary, I would ensure that it does not breach the Stark Laws and the Anti-Kickback statute.
Of note is that the Act allows for the patient to request for transfer even where the emergency condition has not been stabilized. In such case, it would be important that the patient is informed of the risks of the transfer and the obligation of the hospital to stabilize the condition. If after being informed the patient still wants to be transferred, the transfer has to be in writing.
In conclusion therefore, the scenario raises issues for which violation of the Emergency Medical Treatment and Active Labor Act may be committed. The most important thing I would do as an administrator is to ensure that at all times the best is done to ensure compliance to the Act. Importantly also, would be to keep documentation of all decisions, processes, and outcomes. Such documentation may be critical in fighting or defending an EMTALA claim by the patient.
References
Annas, G.J. (1992). The Rights of Patients: The Basic ACLU guide to Patient Rights (2nd ed.).
New Jersey: Humana Press Inc. Print.
Pozgar, G.D. (2012). Legal Aspects of Healthcare Administration (11th ed.) MA: Jones &
Bartlett Learning. Print.
Sharma, D.K. and Goyal, R.C. (2013). Hospital Administration and Human Resource
Management (6th ed.). Delhi: PHI learning Private Limited. Print.
