• Even patches of the holes in the safety net have holes

    A thirty-year-old uninsured woman came to the emergency department of a nonprofit hospital in a north Denver suburb, complaining of difficulty swallowing and breathing because of throat swelling. A computed tomography scan was performed, and she was found to have an abscess at the base of her tongue that was encroaching on her airway. The ear, nose, and throat surgeon on call was contacted, but he reportedly refused to see the patient because she was uninsured.

    Denver Health then accepted the patient as an EMTALA transfer. Throat surgery, followed by a four-day hospital stay, yielded total hospital charges of $15,815.

    This is not supposed to happen under EMTALA (Emergency Medical Treatment and Active Labor Act). Whether you’re insured or not, you should receive condition-stabilizing treatment at the first hospital with resources to provide it. A surgeon cannot legally refuse because of lack of insurance. But one did.

    Now, this is an anecdote. The new Health Affairs article by Sara Rosenbaum, Lara Cartwright-Smith, Joel Hirsh, and Philip Mehler, the source of the quote above,  includes several more, as well as a thorough analysis of the limitations of EMTALA. It’s worth a read. It would be more rewarding to have something like a complete (or representative) data set on EMTALA violations. None exist, which itself is troubling. The authors explain why.

    If you think that everyone in this country is protected from the medical and financial challenges of a major health problem, you’re wrong. The safety net has holes. Even where we’ve patched it (EMTALA), closer scrutiny reveals more. We can do better. We really should.*

    * Opinion, obviously.


    • “A surgeon cannot legally refuse because of lack of insurance. But one did.”

      The article does not go into detail on the call arrangement, but its not clear as to who did what. The hospital needs to ensure appropriate coverage. The surgeon, who may have had a loose affiliation with the facility, may not have been obligated. The days of quid pro quo, ie, hospital provides resources, docs perform ER call at no charge (besides billing for their fees) are over:


      Payer mix of unassigned patients and shift to office-based care (less need to be in hospitals) has changed paradigm. Some hospitals, despite best efforts, cant get specialists in to see folks, even with appropriately vetted stipends. They are in a tough spot.

      Again, unclear what happened in this case, but it may not be so obvious. Hospitals and docs have difft obligations. Screwy, but true.

      Others may want to weigh in.


      • From the article I blogged about:

        “If the initial examination reveals a need for specialized services, the screening physician is expected to notify the hospital’s on-call specialists. Hospitals are required to maintain a list of these specialists as a general condition of Medicare participation. Specialists who fail to respond to a request from the emergency department within a reasonable time can be subject to civil penalties.

        Is it possible to be subject to civil penalties without breaking any laws?

        • Austin
          To clarify, if a physician agrees to do call–either by assignment on a rotating schedule, or is paid–yes, they are obligated to serve. They cant refuse to see someone. They are it, unless they find a substitute.

          However, a hospital cannot call a staff physician and demand they come to the ER if they are not on call. I wanted to clarify what “request” means (your bold).

          Now might there be a special case if an intracranial bleed shows to the ER, and the only neurosurgeon within 50 miles–who is home and not on call–refuses to come in for whatever reason. Dont know. Need a legal mind here.


          • All fine. However, I would not want one nuance to detract from the overall issue of the paper. There seem to be holes, some of them pried open by illegal activity that doesn’t get reported (for reasons explained in the paper). Patients suffer. EMTALA is not functioning as some may think it does.

            • Dont want to beat a dead horse, but this is a very important point: EMTALA is one issue, and getting staff coverage for an ER in another. That is not a nuance. Its another huge problem, but they are inextricably linked.

              We both 100% agree on EMTALA.

            • Fair enough. Not a “nuance.” That was a rhetorical flourish anyway. I didn’t really mean it. 😉

    • Has anyone asked that surgeon how many times in the last 3 years he has had to operate emergently on someone and never received a cent for it? Or if he was ever sued by someone who never paid for his services? The frustration level of doctors is reaching an all-time high, and I’ve seen many doctors who used to be the trumpeters of benevolent medical care become more cynical and cautious about what free care they provide. It’s easy to criticize, but then, that’s only half the story.

      • For the record, I’m not criticizing the doctor. I’m thinking of the patient he refused to see. Maybe the law is flawed. Maybe a lot of things are flawed. Still, people die this way, and that’s a shame in a country as wealthy as ours.

      • Ron:
        As a rule, surgeons are high income individuals. Perhaps, some of their patients are less lucrative than others, but the way to look at this is to look at the net at the end of the year. If you run a grocery store, some of your customers buy steaks, some buy a pack of gum, and some shoplift. Should you continue to run the grocery store? Depends on the bottomline. If you run an airline, some of the passenger pay first-class fare, some pay tourist, and some are discounts. Surgeons typically do not pay for much of the infrastructure required for their work; they have no outlays for the OR’s, the RN’s staffing the OR’s, etc. I don’t think that it is unreasonable to require some in kind payment for a career that is highly paid and has high prestige and honor.
        I am a doctor in the sunset years of my career. It has been a privilege. Much of the bitterness that I see comes from focussing on the material aspects of the job. There will always be someone making more money with less work. None of us are in any real material need.
        The majority of my no pay patients have been good people. Some have been dead-beats, scumbags, and crooks, but they are part of the kaleidoscope of life. Relax and enjoy them.
        Hope I don’t sound too preachy, but people who have the respect and income of a typical surgeon don’t have it that bad.

        • I know your point well. I used to do OB and had many gratus patients during that time. I’ve even given patients cash out of my pocket so they could go buy medications.
          I’m just saying it’s difficult to make judgements when we don’t know the other side of the story.

    • @Brad- Arrangements vary at the hospitals in our system. Some docs get paid for call and some do not depending upon the individual hospital. Mostly, they do get paid. However, at some of our smaller places, the paid docs never come in and everything gets sent out to our network tertiary center. At these very small, rural places it is difficult to get docs to come in for anything sometimes.

      More broadly, the article cites a 2%-7% rate of patients who are sent out of the ER being admitted not long after. This seems to vary quite widely from facility to facility (proprietary data from ER consultant). It is not clear if this practice related or economically driven. Probably a combo.


    • I would think that this sort of problem could be greatly reduced by making it easier for people to become providers (RNs, NPs PAs, MDs Specialists etc.).

      The funny thing is the Government is making it excessively difficult to be a licensed provider because most voters do not see the problems created by such as the politicians faults, but if the politicians take a larger role in health care, as they have in Massachusetts, the politicians will allow the lower licensed people to do more. In France they just have price controls which produce a less academically skilled Doctors.

      Politicians are scum because with a rationally ignorant population of voters that is what it takes to get elected.

      Case in point my supposedly conservative congressman Cliff Stearns, was running ads saying he will keep medicare just the way it is, keep military spending up, and not raise taxes all while cutting the deficit. He really know that the voters are rationally ignorant. Scum.

    • So far everyone is missing the point is that EMTALA is the classic unfunded mandate………….i.e. Congress thinks that communities should provide a service, but is too timid to pay for that service with real taxes.

      Makes liberal congressmen feel good and noble, and keeps conservatives quiet because there are no new taxes.

      Instread of real taxes, the feds have been smuggling money to hospitals through a Medicare subsidy called Disproportionate Share. Why? because Medicare does not have a hard budget. The subsidy is not enough to care for all the uninsured, and some hospitals probably never see the subsidy at all.

      Truthfully, if the uninsured receive decent emergency care 90 percent of the time,(which I think is true), then we should be thankful.

      And we should begin turning at least some ER’s into true public facilities, with enough money to operate even if every single patient was uninsured. Every American pays some level of taxes for fire and police departments, it would not be wrong for everyone to pay taxes for emergency medical care. Where I live in MN, ambulances and parameds are part of the fire department already, though once again they charge user fees and hope that the patient has insurance.

      Bob Hertz, The Health Care Crusade

    • Thanks, Spring Texan.

      The reductions in DSH funding are indeed obnoxious. It was one more example where the backers of the ACA were too timid to raise taxes, so they had to go cruising through existing federal programs to find “savings.”

      Besides, Medicaid patients use hospital emergency rooms at a rate even greater than the uninsured. I am all in favor of the increases in Medicaid eligibility, but no honest observer believes that hospitals will make money on the extra admissions.

      By the way, I forgot to add in my prior post that ambulance services should be paid for by taxes also. Instead of a free municipal service, we have ambulance companies billing $1500 to patients, who hopefully have private insurance to cover this. Just the handling of ambulance claims and co–payments is a huge waste of money.
      It would probably take a payroll tax of one eighth of one percent to have free ambulance service across the USA.