Court Rules EMTALA Covers Patients Not Physically on a Hospital Campus - Emergency Medical Treatment and Active Labor Act

Healthcare Financial Management, April, 2001 by Christopher L. Keough

The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 generally requires a hospital to screen and stabilize a patient who "comes to" the hospital emergency department and requests an examination or treatment. [a] On January 22, 2001, a Federal appellate panel in the Ninth Circuit concluded in Arrington v. Wong that these requirements extend not only to patients who physically arrive at a hospital, but also to patients who are en route to the hospital in an ambulance that is neither owned nor controlled by the hospital. [b]

Although the Ninth Circuit's decision is not binding on courts in other Federal circuits, hospital risk managers and compliance officers should take note of the Arrington decision. As the first reported court decision to apply the antidumping statute to a patient who is not physically present at a hospital, it could have significant implications for hospitals.

The Court's Decision

In Arrington, a patient in respiratory distress was picked up and in transit to the nearest hospital, Queens Medical Center, in an ambulance that the hospital neither owned nor controlled. En route to the hospital, ambulance personnel relayed to the hospital emergency department that the patient was in severe respiratory distress. The emergency department physician requested the identity of the patient's physician. The ambulance personnel responded that the patient's physician practiced at the more distant Army Medical Center. The emergency department physician indicated that he thought the patient should be taken to the Army facility. The patient arrived at Army Medical Center shortly thereafter. By that time, however, the patient's condition had deteriorated, and he died 37 minutes later.

The deceased patient's estate sued the Queens hospital, among others, for damages, alleging a violation of EMTALA. Before trial, the district court dismissed the complaint, concluding that the hospital did not violate the antidumping statute because the patient had never "come to" the hospital. [c] The district court relied on two prior decisions of the Fifth and Seventh Circuit courts of appeals in reaching this decision. [d]

A three-judge panel of the Ninth Circuit reversed the district court's decision by a two-to-one vote. The majority opinion concluded, first, that the meaning of the statutory term "comes to" is ambiguous. The majority of the panel was persuaded that the phrase could mean "either physical arrival at the emergency room or the act of traveling from the scene of an emergency to or towards the hospital."

Having determined that the statutory text is ambiguous, the court then looked to HCFA's regulations for guidance as to the agency's construction of the statute. The court concluded that Medicare regulations at title 42, CFR section 489.24(b), as amended by HCFA in the final rule for the hospital outpatient prospective payment system (PPS), permissibly construe EMTALA to apply to any patient who is traveling to a hospital emergency department in an ambulance, unless the ambulance is not owned or controlled by the hospital and the hospital is on "diversionary status" (ie, it lacks the staff or facilities to receive additional emergency patients)

Analysis

The court's interpretation of section 489.24(b) is not an obvious reading of the regulation. The outpatient PPS final rule defines the phrase "comes to the emergency department" as meaning "that the individual is on the hospital property." HCFA also provides that, for this purpose, hospital property includes "the entire main hospital campus" as well as any off-campus facility that is determined to be "a department of the hospital."

Section 489.24(b) also purports to apply the antidumping statute to patients who are traveling to a hospital in an ambulance. But HCFA also draws a clear distinction between ambulances that are owned and operated by the hospital, which are considered to be part of the "hospital property," and those that are not. With respect to nonhospital-owned ambulances, HCFA's rule provides:

An individual in a nonhospital-owned ambulance on hospital property is considered to have come to the hospital's emergency department. An individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital's emergency department even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. In these situations, the hospital may deny access if it is in 'diversionary status'... [italics added]

In Arrington, the majority opinion construed the last sentence quoted above to mean by negative implication that a "hospital may not deny the individual access unless it is in 'diversionary status."' Thus, in the majority's view, the rule means that a patient traveling in a nonhospital-owned ambulance is "considered to have come to the hospital's emergency department" even if the ambulance has not reached the hospital. Although this reading of the rule clearly conflicts with the second sentence quoted above, the majority opinion in Arrington concludes that it comports with the "overarching purpose" of the statute to "ensure that patients, particularly the indigent and underinsured, receive adequate emergency medical care." [f]