Discussing on-call issues with other specialists is always fun. I am part of an email group of several plastic surgeons from around the country, and one issue that always brings a lively exchange is EMTALA.
For those unfamiliar with medical alphabet soup, EMTALA is the Emergency Medical Treatment and Active Labor Act of 1986. Sometimes it is called “the anti-patient dumping law”.
What it is supposed to do (and generally does pretty well), is to make sure that hospitals do not turn away emergency patients or those in active labor. They must provide a screening exam and stabilizing treatment, regardless of ability to pay.
There are many nuances involved with specialists taking emergency call, and the law can be ambiguous in terms of what is and what is not acceptable. Each type of specialty has its own particular difficulties which arise when they are on-call. Plastic and hand surgery seem to frequently involve EMTALA concerns.
One common situation is the patient with a fracture or cut tendon, something which needs to be definitively fixed, but can be treated first by the E.R. staff and then sent to the specialist’s office where definitive treatment can be arranged. In some cases, specialists refuse to see these patients if they are uninsured. Ethical concerns aside, such a situation likely violates EMTALA, and the E.R. can be cited for failing to require the specialist to come in for the “unstable” tendon.
There are plenty more examples, but it seems that private specialists are reducing their on-call exposure. As margins tighten for private practices, losses from taking call need to be reduced. More hospitals are paying for specialists to be on-call, which is itself another hotly debated topic.
E.R. specialist staffing may become less of a problem in the future, if the trend towards clinical integration continues. For now, with a patchwork of coverage from various private specialists, the EMTALA questions will continue.
Read more about EMTALA:
The website Philly.com noted the increasing trend in bad debts incurred by insured patients. Often, discussions of bad debt center on the uninsured population. With health reform, there will be an increase in underinsured patients, which has been anticipated. What is less obvious is that changes in insurance plans are trending towards higher co-pays and deductibles, especially as employers and individuals seek these plans in order to keep premiums manageable.
On one hand, increased patient responsibility helps to reduce some of the moral hazard utilization issues, present when there is little or no out-of-pocket expense. But if patients are blindsided by high costs that they did not anticipate, hospitals and other providers will see greater unpaid accounts. This adds to the uncompensated care problem, just the same as if these patients were uninsured. And that means that the costs will eventually be borne by someone.
Another concern is that healthcare pricing is far less transparent than it needs to be for patients to be able to make rational comparisons when consuming services. There are also more difficult issues regarding emergency services compared to elective ones.
Hospitals and physicians will need to be aware of high-deductible plans, and make sure that they are managing accounts receivable effectively. For elective services, patients should be made aware of their cost burden up-front. There are numerous reports of wide discrepancies between “retail prices” and “real prices” throughout healthcare. Most importantly, this is a good opportunity to review healthcare pricing at all levels, and work towards a more transparent system.
The Boston Herald discussed some of the unintended effects of Massachusetts’ 2006 health reform law. It is now clear that an expansion of underinsured patients through Medicaid (called MassHealth in the Bay State) results in longer waits for physician appointments.
In an unscientific experiment, the article notes that out of seven primary care offices contacted, only one of them would accept the caller, posing as a new patient with MassHealth insurance. Also noted was that the typical wait for an appointment was 50 business days; two and-a-half months.
The reason appears to be poor or no reimbursement and onerous paperwork associated with MassHealth visits.
Problems such as this seen with the Massachusetts system are very significant, because the national reform law can be seen as a larger version of the same program.
It seems clear that administered prices which do not cover the cost of services provided will not stand over time, and that seems to be the case here. As has also been noted, total system costs exceeding projections have also plagued the Massachusetts program. Fortunately, the national law unfolds over several years, so there should be time to react to these unintended consequences. Massachusetts may again provide examples of what will work and what will not, as they will be facing these problems first.