In the 1970s and 1980s, indigent patients experienced problems at hospital Emergency Departments (EDs) around the country. They were refused care and shuttled to other facilities for services. To protect patients against these types of abuses, Congress passed The Emergency Medical Treatment and Labor Act (EMTALA) in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).·
EMTALA mandates that all patients presenting to the ED – regardless of insurance status – receive a medical screening examination and be medically stable prior to transfer to another facility. If a hospital has the facilities to treat the emergency, the patient can not be transferred to another ED. To address these requirements, every hospital must have physicians on call to assist emergency physicians in assessing and treating unassigned patients.
By the late 1990s, as EMTALA requirements took hold, inadequate on-call physician coverage reached crisis proportions and became a front page issue. In 1999, USA Today carried the following headline: “A Care Crisis in ERs: Nation’s Hospitals Plagued by Shortage of On-Call Specialists” (1). In that same year, Modem Healthcare ran an article with the following headline: “Blaming the Docs: Patient Dumping Probes See Physicians as Culprits in Turning Away Indigent from ERs” (2). In California, a task force was formed to address the matter (3), and the American Medical Association (AMA) began exploring solutions at the highest levels (4).
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Why do hospitals have problems organizing their medical staff to be available to provide on-call treatment of unassigned patients in the ED and subsequent to admission? There appear to be three major reasons for this problem.
First, at a minimum, on-call treatment of unassigned patients creates an inconvenience for physicians, taking away from their personal time; worse. it can reduce the number of available hours they have to spend with their office-based patients.
Second, there are financial disincentives to on-call coverage. Often unassigned patients presenting in the ED are uninsured or under-insured. On-call physicians frequently do not receive adequate compensation for the task of treating these patients.
Finally, on-call duty can bring bureaucratic hassles and/or legal liability for physicians. Dealing with state Medicaid agencies may require addressing administrative requirements, completing paperwork, and paying penalties for not following the rules.
Richard Frankenstein, MD, a pulmonologist in Southern California, admitted an uninsured patient with multiple chronic illnesses when he was the on-call physician at one of his affiliated hospitals. The patient spent 8 weeks in the hospital, much of that time in intensive care. Frankenstein often visited this patient twice a day, so his already busy schedule began hour earlier and ended 1 hour later. He received no compensation for these efforts. That commitment dragged me away from my primary responsibilities,” said Frankenstein. “I’m no longer on staff there, and that situation was a major reason that I resigned (5).
During the past 5 years, the crisis of on-call physician coverage has been significantly reduced and hospitalists emerge as one of the major reasons why. Although there are still issues related to the availability of on-call specialists and surgeons, hospitals that have implemented hospital medicine programs are able to make available experienced general internists to triage, admit, and treat unassigned patients.
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Hospital Medicine Programs:
A Value Added Resource to Hospitals
Hospital medicine programs are characterized by several unique features that facilitate the treatment of unassigned patients and result in significant benefits for hospitals. Figure 1 above illustrates these relationships.
Mark Aronson, MD, serves as a member of the Department of Medicine at Beth Israel Deaconess Medical Center (BIDMC), a 5O0-bed academic medical center in Boston and is also Vice Chairman for Quality and Professor of Medicine at Harvard Medical School. BIDMC has a mature hospital medicine program, and approximately 55-60% of the program’s patients are unassigned, representing more than 25% of the hospital’s general medicine census. Aronson believes that the hospital medicine program provides value to both patients and the institution. He described a case in which a nursing home patient without health insurance presented in the ED. After the initial evaluation, the ED attending decided to admit the patient. One of the hospitalists recognized the patient as someone he had treated several times before. He knew that her medical condition would not require hospitalization and arranged the appropriate treatment, allowing for transfer back to the nursing home. “In this situation, because the hospitalist had a relationship and history with the unassigned patient, the patient received timely, quality medical care and the hospital saved a significant amount of money” (5).