Monday, August 15, 2005

EMTALA, ED Call, and Medicare

I have written previously about the difficulties hospitals and physicians are having with providing on-call coverage. Simply put, many specialists (and non-specialists) view ED coverage as a poorly reimbursed burden, laden with a worrisome risk for malpractice exposure. On the other hand, hospitals need to have specialty coverage commensurate with the services they provide for elective patients -- this was codified by the Emergency Medical Treatment and Labor Act (EMTALA), passed in 1986.

Given today's falling reimbursement (particularly from Medicare, but also all insurers), rising malpractice rates, and increasing numbers of uninsured, some physicians are trying to opt out of or decrease their ED call coverage. Presently, many facilities are starting to pay for ED specialist coverage, or are considering employment agreements. While those responses take dollars out of the system, they do have the advantage of ensuring the hospital is EMTALA-compliant. Some hospital associations, however, have tried to take a different approach -- trying to get the Centers for Medicare and Medicaid Services (CMS) to link on-call requirements to Medicare participation. A federal advisory panel that meets twice per year to review EMTALA issues recently voted against that proposition, albeit by a narrow margin. Full details can be read here in the article entitled "Panel Says 'No' to On-Call/Medicare Link."

If such a link were enacted, however, "physicians would quit Medicare in droves, " Dr. Bayer told this newspaper. Participating in Medicare means "you abide by the rules and have to accept the payments, but it has never been linked to anything like this before."
"We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine," Dr. Nepola said. "Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving towards boutique practices, which I abhor."
I can easily see certain fields where physicians would simply say "don't throw me in that briar patch! OK, I won't take ED call, and I won't see any Medicare patients either! I'll just line up all of those knee scopes (or lumbar diskectomies, or skin lesion biopsies, or routine physicals......) and make sure the poor ED physician can never interrupt my elective schedule again!"

I admit I have mixed feelings about all of this. Clearly, mandating ED call coverage to allow participation in Medicare is a very poor solution, and would never work. By the same token, patients with emergent problems need access to specialists; we also have a responsibility to care for those patients when we are on call. As with everything else in our society, the true solution can be found in the free market ---- if the majority of patients seen in the ED provided physicians with enough reimbursement to make coverage financially viable, more physicians would be interested in providing that service. However, these days, the free market isn't allowed to be applied in medicine, and that just ain't gonna happen!