Advisory Panel Starts Shaping EMTALA Policy : The technical group's physician members hope its final report will make on-call service more workable.


For a copy of the EMTALA technical advisory group's final report, visit

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.


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