The San Diego Union-Tribune

An effort by the Bush administration to clarify rules that require hospitals to provide initial care to any patient who comes in requiring emergency treatment is creating as many questions as answers.

The new rules, which take effect in November, will provide hospitals with greater discretion in staffing their on-call rosters, give hospital ambulances more flexibility in handling emergency patients and limit the scope of where the law applies.

In general, the extra wiggle room is welcomed by the hospital industry, which supports the revisions. But some local hospital chief executives, who will be reviewing the changes over the next several weeks, have expressed concerns about additional uncertainty as hospital staffers adjust, said Steve Escoboza, president of the Healthcare Association of San Diego and Imperial Counties.

“To the extent that these new rules may provide some flexibility, we might get some confusion in interpretation,” Escoboza said. “When we’re coming from an inflexible and well-known position after all these years, that has a tendency to create confusion.”

The new rules are revisions to EMTALA, the 1986 Emergency Medical Treatment and Labor Act, sometimes referred to as the “patient anti-dumping statute.” The changes go into effect Nov. 10.

The law stipulates that hospitals with emergency rooms who participate in Medicare must screen, stabilize and, if necessary, transfer any patient who comes in needing emergency treatment, regardless of the patient’s ability to pay.

The basic core of the law will not change, said Leslie Norwalk, acting deputy administrator of the federal Centers for Medicare and Medicaid Services.

But some consumer advocates worry about what sort of effect giving hospitals more flexibility may have on patient care.

“It is clearly giving hospitals some fudge room to cut back on taking people in, keeping them there and having an ample network of specialists ready to meet people’s needs,” said Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights in Santa Monica.

According to the revisions, staff at hospital-owned facilities away from the main hospital campus no longer have to screen, stabilize or transport emergency patients to the main hospital; they can call 911. Ambulances owned by a hospital no longer have to take patients to that specific hospital; they can take them to another facility.

Hospital administrators can staff emergency on-call rosters as they best see fit given the hospital’s capabilities. Doctors can be on call at multiple hospitals at once, as well as when performing scheduled surgery.

Too much discretion, Court said, could hurt patients.

“The balance of power is shifting away from obligation on the part of the hospital to have ample specialists on call,” he said. “Flexibility in an environment like that means space to cut back on care.”

The idea of the revisions is not to skimp on care but to clarify gray areas in the law, said Norwalk, so that hospitals don’t waste time and money taking what could be unnecessary precautions to avoid penalties. Hospitals found in violation of the law could face a penalty of as much as $50,000 and suspension of their participation in the Medicare program, which could wipe out a large part of their revenue.

“They were focusing a lot on ‘Did we cross the t’s and dot the i’s?’ ” Norwalk said, adding that complaints from physicians, hospital administrators and others in the health care industry largely fueled the changes. “They were worried about the giant nuclear bomb of an EMTALA violation.”

The relaxed rules will indeed help ease the burden of liability for doctors, said Dr. Brian Johnston, an emergency physician in Los Angeles and trustee of the California Medical Association, which supported the changes.

Most doctors are in accord, but questions remain. Dr. David Guss, director of the emergency department at UCSD Medical Center, supports the changes overall but sees the on-call roster revisions presenting a glitch.

With hospitals being told they can staff rosters as they see best, on-call staffing holes could result at some hospitals, he said. That in turn could lead those hospitals to send emergency patients in need of specialists to UCSD.

“If the other hospitals don’t have everyone on call, they default to those hospitals that do,” he said. “It increases the potential burden for UCSD.”

At the same time, Guss doesn’t think the new rules will have an adverse effect on patient care. He believes the changes could save hospitals money not only in administrative costs but also in terms of limited exposure to risk.

Norwalk said there could be a tangible financial impact for hospitals as they spend less on administrative costs — for example, on the cost of training staff at a nonemergency facility off campus to recognize an emergency medical condition.

Local hospital officials say that would be nice, if it happens.

“From a financial standpoint, it’s too soon to tell,” said Tamara Hemmerly, a spokeswoman for Palomar Pomerado Health, which operates the only trauma center in North County. “If we have that type of savings, it’s a bonus. But we will continue to provide care to those in need.”
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Leslie Berestein: (619) 293-1542; [email protected]