Government Belligerence Isn't the Answer to Fixing Healthcare
I've written here often on how government oversight of medical areas goes wrong, whether it's committees to reduce maternal mortality or how to keep rural hospitals open. Recently the news has reported government actions in enforcing the EMTALA law. The law covers any emergency care, but has become associated with hospitals turning away pregnant women in labor. When rural hospitals turn away pregnant women, the nearest hospital may be 100 miles away.
On the surface, this appears a reasonable law, but in practice, it is failing to protect pregnant women. The question that needs answering is why. Fining the hospitals for violation of EMTALA doesn't solve the problem. Again, why does belligerence fail to solve the problem much less correct the problem. Recent stories of government enforcement of EMTALA follow the usual belligerence road.
In my home state, North Dakota, which is largely rural, there are five hospitals involved in EMTALA actions. The law requires an initial medical screening examination to determine whether a true medical emergency exists. In the case of pregnant women, this includes evaluation of two people, the one who is pregnant and the baby in the uterus. The patients must be either stabilized and/or appropriately transferred. We shouldn’t need federal regulations to tell us that.
A recent Scripps article reports that a hospital in Harvey, North Dakota, St. Aloysius, has come under investigation for EMTALA violations. According to the article. a 32-year-old woman at 36 weeks in her fourth pregnancy presented to the emergency room with a backache that was similar to labor. She was 2 cm dilated. We were told nothing about fetal distress. We are told that the patient was refused care, refused stabilization, and refused safe transport to a hospital with a higher level of care where obstetrics was done on a regular basis—a hospital 73 miles away.
To make matters much more complicated, the patient was also refused an ambulance to another hospital. Apparently, the hospital didn’t have one running at that time. Neither was the patient given any supplies or equipment in case she delivered in the car. No towels or blankets.
The patient and her husband returned to their home, got some blankets and picked up the other kids to take them along. To make a long story short, she delivered in the car on the 73-mile trip to the distant hospital.
According to the EMTALA interview of the doctor, (who remained nameless) he couldn’t keep the patient at St. Aloysius because they had no monitoring equipment. As an obstetrician who actually worked in Harvey and delivered babies there from 2007 to 2013, I can read between the lines and understand what really happened here. As usual, the doctor gets the blame. Knowing how things work in hospitals, and particularly in Harvey, the doctor made a decision for many people. I’m sure he had several nurses and perhaps even a CEO telling him to not do the birth or keep the baby there.
What should have happened in the St. Aloysius emergency room is the issue which needs to be addressed. In the first place, not having the necessary monitoring equipment is an extremely poor excuse for turning away a pregnant woman in labor. All you need is a stethoscope to listen to the baby before, during, and after a few contractions. Every hospital, no matter how big or how small, should be prepared for the fact that there are going to be pregnant women living in the community and they might not be able to get to a hospital 70, 80 or 90 miles away, especially in the winter time. Every ambulance is equipped with emergency delivery equipment. Every hospital should have the same equipment in the emergency room. Furthermore, an electronic monitor is not that expensive and could be available.
From an ethical viewpoint, both mother and baby would have been much safer delivering in the emergency room. To send this mother out under the conditions and circumstances that prevailed is completely irresponsible. When you send a patient out to avoid the risk of dealing with the patient in the emergency room, the risk doesn't go away. It just gets pushed to some other entity. In medicine, we call this lateralization of risk. In other words, getting rid of perceived risk to the hospital, nurses, and providers simply shifts the risk elsewhere, in this case to the patient. This lateralization of risk is a moral and ethical dilemma which every small hospital must deal with. It is not that laterization of risk couldn’t be addressed, but simply that in the EMTALA situation, lateralization of risk hasn’t been addressed.
In another small town I practiced in, the hospital did not do deliveries. One night a woman came to the emergency room in labor. I was called into the emergency room to see the patient. The nurses wanted to send her off in the ambulance to a hospital 60 miles away with me riding along. Upon examination, I could tell that the woman would likely deliver in the ambulance on the way to the hospital. I told the nurses that I would rather deliver the woman in the hospital than in an ambulance on the way to another hospital. We did not send her off in an ambulance and she successfully delivered in the hospital. Physicians should be making the decision whether a patient stays or is sent off in an ambulance and nurses should be supportive of the physician's decision.
The American College of Obstetricians and Gynecologists (ACOG) Harm to Rural Hospitals
ACOG needs to own the harm boarding restrictions have on rural hospitals. I was boarded by ACOG when I moved to Harvey. I had to see male patients because they the hospital couldn’t afford to pay me for sitting on my hands half a day at a time. So I was unable to renew my ACOG boarding because of my living and providing obstetrical services in a small town. ACOG needs to recognize and own the harm they are doing to rural medicine by this unneeded restriction on physicians.
Correcting Medicare and Medicaid Reimbursement Problems
One of the problems for hospitals is that a large percentage of the costs of providing EMTALA care is never reimbursed by Medicare or Medicaid. Hospitals have to provide the care whether they ever receive payment or not. If hospitals are required to provide the care whether the patient has insurance or not, Medicare and Medicaid should be required to pay for the care EMTALA requires by law including an ambulance.
Most people don’t know that Medicare providers in North Dakota are considered to provide very good care to patients. Medicare rates North Dakota as one of the top ten Medicare providers in the United States, but Medicare pays North Dakota providers less than it does in 47 other states. There are only two states in the union where providers are paid less. Senator Conrad tried for years to get this problem addressed but was unsuccessful in removing the disparity. This is politics. North Dakota has one representative and any effort to remedy the payment discrepancy could easily be voted down by other states. Medicare should reimburse all providers the same, regardless of whether they practice in California, North Dakota, or New York.
Correcting EMTALA Belligerance With Helpful Training
Certainly, there is a lot of room for education in a situation like the one which occurred at St. Aloysius in Harvey. But everybody would need to be educated, not just the providers or patients. I am talking about the hospital boards, certainly local, as well as distant, hospital CEOs, nursing leadership, and all of the nurses. The Center for Medicare and Medicaid Services (CMS) has announced efforts to help hospitals manage EMTALA services. This is certainly a step in the right direction, but will the suggestions for helping hospitals meet their EMTALA obligations ease the belligerence of current enforcement efforts. The draft of CMS's recommendations to help hospitals meet EMTALA requirements is still very short on recommendations for providing training and guidance to hospitals on how to be prepared and ready to meet EMTALA requirements and are still very heavy on punishment for violations of EMTALA. Government belligerence is not the way to remediate EMTALA violations. Time the government replaced belligerence with a helping hand, which is much needed.