When does the duty to provide emergency medical care end?

by Lyle Denniston

Hospitals know that medical care decisions often have legal consequences, which makes it all the more important to know what the law requires. But when judges can’t agree, and there also is some ambiguity in the way government officials see a legal issue affecting care decisions, hospitals may need to go to the ultimate authority – the U.S. Supreme Court – for an answer.

A Southfield, Mich., hospital, Providence Hospital and Medical Center, has done just that, in a plea to find out when, in legal terms, its duty to provide emergency medical care ends. The court is now seeking some outside legal advice – from the Justice Department — before deciding whether to settle a fundamentally important question under the federal “Patient Anti-Dumping Act,” formally the Emergency Medical Treatment and Labor Act of 1986.

The Act was passed to assure public access to emergency medical care regardless of ability to pay, length of stay or medical practice standards. It applies to all hospitals that take part in Medicare and that operate an emergency department of their own.

Any patient brought to such an ER has a right, under the Act, to a medical screening and, if an emergency condition is found, a right to care that will stabilize the condition, or else a transfer to another facility if that seems medically appropriate. Stabilizing care means treatment that will prevent further deterioration of the emergency condition.

But Providence Hospital has asked in its appeal to the Supreme Court, when does the duty to provide emergency care end? The answer the hospital is proposing – and it is an answer that a federal government regulation issued seven years ago supports – is that the duty to provide care ends if the hospital decides to admit the patient for further evaluation or further treatment, or both. In other words, Providence’s view is that the 1986 law is an emergency room law, and its mandates apply in that setting only.

An admission and subsequent discharge muddies the water

The issue arises for Providence because, in 2002, an ER patient it evaluated and found to be mentally unstable, who was admitted for in-patient care, left the hospital after six days, went home and murdered his wife. A federal judge ruled for the hospital, saying this federal law did not control what the hospital did after the patient was actually admitted. The Sixth U.S. Circuit Court of Appeals ruled just the opposite, saying the law goes beyond the emergency room, and imposes care duties no matter how long the patient remains at the hospital. The circuit court also disagreed with federal officials, who had ruled in 2003 that an in-patient admission fulfills any emergency care duty that the federal law imposes. (Earlier, federal officials thought the stabilization requirement continued after admission, but they changed their minds in 2003.)

Because other U.S. courts of appeals disagree with the Sixth Circuit on the point, Providence Hospital took its case to the Supreme Court. Since there is a serious risk of being assessed civil damages (either by the federal government or in a private lawsuit), the hospital argued, the court should clear up the legal obligations that the Act imposes. It also contended that the Act should mean the same thing everywhere in the country. The hospital has a good chance that the Supreme Court will agree to hear the case, since the Court quite often chooses cases where the lower courts are in conflict.

Rather than take action itself immediately on the case, however, the court in January passed the case along to the Justice Department’s Office of the Solicitor General — an office to which the court often turns to get help in understanding what a federal law actually means. The solicitor general has no timetable for responding, but is expected to do so fairly soon. After that, the court will then make up its own mind whether to decide the case.

Lyle Denniston is a legal reporter and is a regular contributor to Curaspan Health Group’s Knowledge Exchange.

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  • PAULMD

    This is fascinating and extremely important for ALL of us. I would like to see follow-up in this blog as this evolves if you don’t mind. Thank you.

  • Bladedoc

    Here’s my guess. The law will be found to mean whatever costs the federal government the least and imposes the most costs on the hospitals. But maybe I’m just cynical.

  • http://nostrums.blogspot.com Doc D

    The extent of the medical facility’s duty to a patient seems a part of the larger question of the ethical “duty to follow.” Caregivers incur this duty to a patient with whom a relationship has been established.

    As a parallel, I’m thinking of the physician, or clinic’s, responsibility if a patient acts or fails to act as recommmended: the failure to follow up from a positive fecal blood test, or being a no-show for screening mammography. The lawyers recommend a positive effort to follow through on the commitment to the patient’s, or their proxy’s, best interest. In my experience, registered letters to the patient are used. Some patients respond, some don’t. But, if they don’t, at some point you have to say, “I did what I could, and have no further duty.”

    It’s not clear from the description above whether the hospital exercised due diligence in how the patient left the hospital. It makes a difference; discharged for lack of funds, discharged improved and thought to be not a risk, signed out against medical advice (and competent to do so), among others.

    Legal wrangling over the intent of the law is IMO less important than the ethical duties involved. I, too, would like to hear more as this case moves forward.

    • Dr. J

      Do you really believe that a patient can show up in an emergency room, impose a burden of charitable care on you because you are on call, and then that burden extends not only to the immediate emergent condition but also as a ‘duty to follow’. You mention breast cancer screening, are you really of the opinion that the ‘relationship’ between doctor and patient in an emergency room imposes an endless duty to follow these patients and get their (completely non-urgent) screening medical care done (at no cost since these are non paying patients)?
      The difference between charitable care and servitude is choice…

  • Vox Rusticus

    Let’s take the occult blood example a little further. Is it also the hospital’s duty to require one of its surgeons to perform a colonoscopy, a procedure that is routine and not emergent? Suppose a suspected tumor is found. Does that require the hospital (and its staff, who may not be employees) to also provide resection and follow-on care? At some point, care both leaves the emergency department and becomes as routine as any other care. The need or urgency of a patient with an occult blood test is no greater for the ED patient availing himself of EMTALA than it is of anyone else in their personal physician’s office seen as an outpatient, never setting foot in an emergency room.

    The EMTALA law has never enjoyed a definite and clear definition of “emergency,” “stabilize” or “treatment.” I have read interpretations as broad as to include someone presenting in the hospital grounds parking garage being as entitled to EMTALA as someone in the emergency department, and loose interpretations of “transfer” to higher echelons of care to include all outpatient referral and follow-on management.

  • http://www.generalmedicalbooks.com Taylor MD

    Very interesting. This may be important for the hospitalists. When they admit patients from ED without insurance, the hospitalists try to set them up for follow up with “city call” or some other mechanism where one of the primary MD is forced to accept the patient for one follow up visit after discharge. But what happens after that? If something bad happens, who gets the blame? Hospital and therefore the hospitalist is required to see the patient but primary MD is not.

  • PAULMD

    I find myself trying to dissect the “establishing of a doctor patient relationship” in regard to the forced meeting of the two participants because of EMTALA and or hospital bylaws.

    I will be frank that I don’t consider this establishment of a relationship to be as morally or ethically binding as when one is made by mutual consent by both participants and not forced participation by regulatory coercion.

    Just because our parents MADE us go out on this first date doesn’t mean we have to get married.

  • http://www.feldtman.com/resume.html Bob Feldtman

    On specialty call for ER; EMTALA says you must come; hospital credentialling says you must come and treat; you do, admit, operate, treat, followup – and patient has no insurance, pays nothing, is demanding for more followup. When do you says adios ?? Or are you “stuck” being this doctor for nothing forever Amen Sure, done with your care, but patient wants meds, labs, other stuff.. how do you say go elsewhere for care aft4er the emergency is over? Oh, hospital pays nothing, I am in private practice. What is definition of slavery?

    • Vox Rusticus

      If you were to ask me, I would say that once the patient is no longer in the hospital, you have the right to insist on payment as a condition for further care, just as you would with any other patient seeking care. The notion of doctor-patient relationship is turned on its head when one party seeks to impose terms the other is unwilling to accept–non-payment here. As non-payment is a recognized reason for terminating a doctor-patient relationship otherwise, once the patient is out of the ED, it should be just as valid a reason for that patient as for anyone else. A patient is not entitled to insist on continuing care on whatever terms he declares, including non-payment.

  • Muddy Waters

    This is why I refuse to see most consults in the hospital. As long as you do not lay eyes on the patient, you are legally responsible for nothing. I may accept a rare inpatient consult, but mostly have them follow-up outpatient once discharged (and where they ARE responsible for the bill). The hospital can take my credentialing if they want to, because I am really just doing them a favor anyway.

    • Vox Rusticus

      I have to second the point made above that the relationship established under EMTALA is not necessarily voluntary, at least for the doctor who comes in not because he wishes to but because he is required by hospital bylaws to participate on a call schedule to maintain staff privileges. Unlike the ED doctor, who voluntarily contracts with the hospital to work in the ED, the active staff member in private practice does not have the same relationship with the hospital. That said, I doubt EMTALA or any of its requirements depend on the presence of that relationship; they are two independent and unrelated ideas, one the fulfillment of a staff bylaw requirement and the other a professional duty.

      What has appeared to evolve from EMTALA has been a requirement of on-call doctors to follow the patient until the patient has “stabilized.” which is a very nebulous definition, subject to various interpretations. At times, I have followed ED-referred patients for over a week who have no coverage for serious infections before stopping them at my front desk for lack of payment, not necessarily out of charity but because I wanted no opportunity for someone to later claim “abandonment, ” (as if expecting a professional to work for you for free should be something one might complain of as abandonment once denied, go figure.) At other times, I offer no leeway when I am given the impression that the patient expects referral care on the same unpaid terms on which he left the ED.

      Morally, I would say that no one should expect free labor from another. Of course, we do not live in that ideal universe, but I see nothing wrong with requiring someone requesting service with no payment provide proof of their inability. That never seems to happen either. For the most part, I hear “I have no money” meaning ” I can’t pay my whole bill and would really rather not bother, even if I could pay over time.”

  • ninguem

    The doctors get to find out what the rules are as they go along.

  • gzuckier

    Well, it’s a small price to pay to be free from the dread spectre of Socialized Medicine, eh?

  • http://survivingtheemergencyroom.blogspot.com/ Ron Clark, M.D.

    EMTALA (anti-dumping law) is for unstable patients who present to hospitals who have Emergency Departments who receive Medicare funding. It requires a medical screening and stabilization of condition. If the patient does not have an unstable condition the law does not apply. Interestingly, the law imposes a requirement on Emergency Physicians to the federal government, but does not provide civil penalties for patients who have a perceived or actual complaint against on Emergency Physician. In my view as a practicing Emergency Physician at the Hospital of Central Connecticut, if the Emergency Physician provides a medical screening exam and treats the patient, admits the patient for further testing or procedures, or transfers the patient to another hospital that has a specialist that is needed with the consent of the receiving hospital, in good faith EMTALA has been followed. We will see what the courts say, but all I can control as an Emergency Physician is what happens in the Emergency Room (when the patient is admitted, transfer of medical responsibility goes to the in-patient physician). The whole notion of EMTALA is for the law to ensure that all people can obtain emergency medical care regardless of their ability to pay. When the emergency medical care is completed, the EMTALA requirement should be viewed as fulfilled- we will see. -Ron Clark, M.D.
    http://www.survivingtheemergencyroom.blogspot.com/

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