Supreme Court gives EMTALA more teeth

Hospitals hoping for relief from patient dumping rules suffered a setback after the Supreme Court ruled that a patient could sue a hospital that transferred her to a nursing home. The decision comes on the heels of a November OIG/HCFA warning that regulators are preparing a special advisory bulletin that will put more teeth in the federal anti-dumping statute.

The court decision will spur yet more dumping suits, predicts Joseph Mattingly, the Lebanon, KY-based lawyer who represented the patient in the case. Claimants whose cases were dismissed by various lower courts now will have grounds to refile their cases, says Mattingly. But Mary Grealy, Washington, DC, counsel for the American Hospital Association, says that the facts of the case are so unique that it will have little impact.

The Supreme Court decision involved Wanda Johnson, a woman who was hit by a truck in May 1992 and taken to The Humana Hospital - University of Louisville in Kentucky. After six weeks in unstable condition, the hospital sent her to an Indiana nursing home, which in turn sent her to an Indiana hospital after her condition worsened. After Indiana Medicaid refused to pay her medical bills because she wasn’t a state resident, Johnson’s guardian sued Humana under the Emergency Medical Treatment and Active Labor Act (EMTALA). Her suit was filed under Section 1395 of EMTALA, which requires hospitals to properly examine and stabilize patients.

A federal district court and an appeals court both dismissed the case on the grounds that EMTALA required the plaintiffs to show that either the medical decision claiming Johnson was stable, or the decision to transfer her to a nursing home, was prompted by improper motives such as her age, race, or finances. But the high court ruled that Section 1395 of EMTALA did not require proof that the hospital acted from improper motives. The case was remanded back to the lower courts, where Mattingly expects it will be resumed or settled in the spring.

While the decision was a victory for the plaintiffs, it was not a definitive one, says Mattingly. Both sides in the case were disappointed that the court didn’t give concrete guidance as to what’s needed to prove patient dumping. Instead, the Supreme Court merely ruled that the question of a hospital’s motives did not invalidate such a case. "This doesn’t settle any of the issues," says Grealy, adding that the decision would have been momentous only if the court had ruled that the plaintiffs needed to prove the hospital acted from improper motives. "That would have raised the bar in these cases," she notes.

The key issue of the case was whether it was appropriate for the hospital to transfer a patient to another facility, Grealy argues. EMTALA was just intended to ensure that patients could get emergency care, but Johnson had received six weeks of care before she was transferred.

The federal anti-dumping statute mandates that patients must get a proper screening exam and emergency treatment, and that a patient’s condition must be stabilized before he or she can be discharged, according to the OIG bulletin. An unstable patient may be transferred only if a doctor certifies that it is in the patient’s best interest.

But Mattingly’s advice for hospitals is to remember that stabilizing a patient for purposes of EMTALA differs from the medical definition of stabilization. "When a doctor says this patient is stabilized, he’s thinking in terms of medical stabilization," he adds. But that’s essentially a short-term assessment. EMTALA views stabilization as meaning a patient’s condition will remain stable for the long term, and he or she can be safely transported to another location, Mattingly says.

OIG statistics show that during FY 1998, the agency settled 54 dumping cases that netted $1.8 million in penalties. In addition, it took administrative action against three doctors and a hospital. Another doctor was fined $100,000 for dumping two patients in a case that’s under appeal.