Not too long ago, I believe at the recommendation of Walter Olson at Overlawyered, I started reading WhiteCoat Rants (renamed WhiteCoat’s Call Room when he moved to Emergency Physicians Monthly), an anonymous blog authored by a voluble ED doctor.

I have over 300 feeds in my Google Reader, including venture capitalists, scientists, professors, economists, security professionals, and ship captains, and while I frequently read Grand Rounds, I didn’t regularly follow many practicing physicians.

So, what the heck.

I didn’t expect to comment or to debate, just get another perspective. I have my own blog in part to channel the temptation to respond when Someone Is Wrong On The Internet into a more productive form. That said, I think it’s worthwhile to chime in on another blog when I think it will add value to the discussion, which is what happened with WhiteCoat’s defensive medicine post, my response, his reply, and my sur reply.

Defensive medicine is a controversial topic made worse by the absence of good empirical data about its existence or prevalence. A GAO study in 2003 found the effect to be minimal and possibly non-existent, and I think the whole idea of “defensive” medicine is conceptually flawed, but it’s such a broad, hot-button subject that I don’t expect many minds to change one way or another over it.

I didn’t expect the same for EMTALA.

Here’s the American Academy of Emergency Medicine (AAEM):

The Emergency Medical Treatment and Active Labor Act (EMTALA) was included in the COBRA legislation of 1986. It was promulgated to combat the discriminatory practice of some hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of the high cost associated with diagnosing and treating these patients with emergency medical conditions. While the Act applies to all Medicare participating hospitals, it protects anyone coming to a hospital seeking emergency medical services, not just Medicare beneficiaries. EMTALA imposes strict penalties including fines and exclusion from the Medicare program for violations of the Act. The Act imposes three primary requirements on Medicare participating hospitals that provide emergency medical services.

  • The hospital must provide an appropriate medical screening exam to anyone coming to the ED seeking medical care;
  • For anyone that comes to the hospital and the hospital determines that the individual has an emergency medical condition, the hospital must treat and stabilize the  emergency  medical    condition, or the hospital must transfer the individual; and
  • A hospital must not transfer an individual with an emergency medical condition that has not been stabilized unless several conditions are met that includes effecting an appropriate transfer.

Emphasis mine to highlight some issues.

In my view, EMTALA reflects the way that most people expect an emergency department to function. If you go to an emergency department, they will check to see if you have an emergency and, if so, will treat you until you no longer have an emergency. The outrage that follows every “patient dumping” story supports this view; it’s also no small matter that the winning Presidential candidate explicitly endorsed medical care as a “right.” (EMTALA implicitly creates a “right” to emergency medical screening and stabilizing at Medicare-recipient hospitals by permitting patients to sue if they are denied that “right.”)

I’m not surprised that emergency physicians dislike a law that requires they spend their time (and hospital resources) screening and stabilizing individuals who often can’t or won’t pay, at least not pay enough, particularly as emergency departments increasingly become the de facto primary care physicians for millions of Americans. It gives them the burden of being a first-responder without the benefit of stable salaries and guaranteed government funding.

What surprised me was the anathema was directed at the concept of EMTALA rather than the execution, even as the physicians spoke of wanting to ensure access to healthcare for all.

Just as most people expect the ED to check them out when they have a problem, most people expect that the ED will be funded in some reasonable fashion. If you have private insurance, your insurance will be billed. If you are on Medicare, Medicare will cover. If you are impoverished, Medicaid will cover, even for undocumented aliens.

But that’s not how it works in the real world. There’s a reason that an industry like “professional coding” — not even middlemen, but people who input data for use by middlemen! — exists. Health insurance companies routinely deny reasonable care already performed. Medicare reimbursements are low and difficult to process, and Medicaid is worse than Medicare and not even fully funded in the first place.

Some suggestions for reforming the economics behind emergency medicine make sense, like this one from the American College of Emergency Physicians:

Some health insurance plans deny claims for legitimate emergency departments visits, based on a patient’s final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack). Some also attempt to require preauthorization before a patient can seek emergency medical care, resulting in denied payment. These managed care practices endanger the health of patients and threaten to undermine the emergency care system by failing to financially support America’s health care safety.

ACEP advocates for a national prudent layperson emergency care standard that provides coverage based on a patient’s presenting symptoms, rather than the final diagnosis. In addition, health insurers should cover EMTALA-related services up to the point an emergency medical condition can be ruled out or resolved.

But for every specific, reasonable proposal like that, you get a complaint like this (also from ACEP):

According to a May 2003 American Medical Association (AMA) study, emergency physicians annually incur, on average, $138,300 of EMTALA-related bad debt. Approximately 95.2% of emergency physicians provide some EMTALA mandated care in a typical week and more than one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.

Sounds bad, but those figures are useless since they’re a mish-mash of several distinct problems.

What does “EMTALA-related” mean? A prior paper of ACEP’s defined “uncompensated care” and “bad debt” as any care where the physician or hospital collected less than they billed, which means every denied private insurance claim, every denied Medicare claim, and every denied Medicaid claim in addition to the totally unreimbursed care most people assume is meant by “EMTALA-related.”

Which means the “EMTALA-related” figure above conflates every single billing issue affecting emergency departments into “EMTALA-related bad debt,” even where most of it has nothing to do with EMTALA.

Combine that with self-congratulatory, self-contradictory praise like “Emergency physicians are proud to serve as an essential part of the nation’s health care safety net, open 24/7, caring for everyone, regardless of ability to pay or insurance status,” and you have to wonder if anything’s actually wrong with the system if they “proudly” follow EMTALA’s dictates yet blatantly manipulate numbers to oppose EMTALA itself.

That’s what I wanted to describe to WhiteCoat when he again raised the specter of EMTALA as the cause of several ED stories, including the closing of the ED at Northeastern Hospital here in Philadelphia. I posted a comment.

He took it to heart.

I don’t agree with his conclusions (no surprise), and a discussion on the merits is best left until later, but it’s gratifying to see that I could offer him and his readers a different perspective, just as they’ve offered me.