ERP and I had a discussion yesterday
that raised some interesting questions which I believe warrant further consideration. His post was about the frustration with the unpaid mandate of EMTALA and the related lawsuit by some California physicians seeking increased reimbursement for their treatment of Medicaid patients.
He complained that since ER docs are legally required to see these patients, it isn't fair that we aren't reimbursed adequately for our services. I reminded him that a new model of emergency medicine is emerging, the freestanding ERs, some of which do not accept Medicare or Medicaid and therefore are not legally required to follow EMTALA. His position is that such facilities are not really ERs at all, that it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.
Perhaps he is right, but one could make the same moral
argument for all physicians regardless of specialty. Shouldn't all physicians have the quality of beneficence? Yet
only emergency physicians and those specialists taking ER call for a Medicare-participating facility are legally required to provide unreimbursed care. When we try to define the essence of the practice of Emergency Medicine, are we talking about the legal requirement or a moral requirement?
The legal requirement is undefined. A facility may provide emergency medical services without being open 24 hours a day or 7 days a week. There is no legal requirement that an ER must be physically attached to a hospital, affiliated with a hospital, certified by JCAHO, or even staffed by trained or experienced emergency physicians. Board certification is certainly not required, whether in EM or by any other specialty. And, perhaps most importantly, there is no legal requirement (yet) that any ER, physician, or medical facility accept Medicare or Medicaid.
Some rural ERs are reportedly staffed by a single unsupervised physician assistant, according to one of my commenters. Others are not supported by adequate hospital facilities to manage complex injuries or illnesses, so the sickest or most injured patients must be transferred elsewhere. Most hospital-based ERs without comprehensive specialty backup must at least occasionally transfer neurosurgical injuries, ophthalmic injuries, penetrating trauma, pediatric cases, or a variety of other conditions based upon the expertise of their medical staff or the whims of their call schedule. Others must transfer patients when there are no available inpatient beds. Is such a facility more of a "real ER" than a for-profit freestanding ER with similar staff, more sophisticated equipment, and superior specialty backup? Of course not.
What of the case of the University of Chicago ER, who technically followed EMTALA when they medically screened, stabilized, and discharged
the boy whose lip was bitten off by a pit bull? They certainly met the legal definition of an ER that night. In some cases, EMTALA causes us to provide worse care than if that law didn't exist. When an ER whose hospital has no trauma surgeon on staff receives a walk-in patient with a gun shot wound, they often waste precious time "stabilizing" the patient and trying to find an appropriate accepting hospital when the patient might be better served by simply calling 911 from the lobby and sending him immediately to the nearest trauma center. When a patient who has been sexually assaulted presents to an emergency facility without the properly trained staff to collect forensic evidence, she doesn't need to wait 2 hours for a receiving hospital to send the transfer paperwork, she needs to be directed to the proper facility without causing her any more discomfort and delay than necessary.
Following natural disasters, I've worked in emergency departments (yes, pleural) without power, using a headlight to find my way down the hallway. We had no X-ray or laboratory facilities whatsoever, so for those weekends we were essentially practicing 19th century emergency medicine. And yet we were still an ER, both by my definition and ERP's, because we turned no patient away. All you really need in an ER is a good doctor, a good nurse, some basic equipment, and good sense. Increased assets make some ERs more capable than others, but the underlying job is still the same: diagnose, stabilize, and make a proper disposition.
I don't think that emergency physicians should be held to a higher moral standard than physicians of any other specialty, and I believe that all physicians who choose not to work for the government should have the right to refuse to treat any patient. Of course we can and will continue to provide charity care, but we will do so because we are compassionate physicians, not because the practice of Emergency Medicine specifically requires it of us. By refusing government subsidies and freeing ourselves from the requirements of EMTALA, we will be empowered to control the frequency and volume of our charity like other citizens.
Labels: ER, health care crisis, rants