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Patients need not prove improper motive
By Claudia A. Hinrichsen, Esq.
Nixon, Hargrave, Devans & Doyle LLP
Long Island, NY
In January, the Supreme Court, in Roberts v. Galen (119 S. Ct. 685 1999), held that patients who claim to have been "dumped" in violation of the anti-dumping statute — the Emergency Medical Treatment and Active Labor Act (EMTALA) — need not prove that the hospital acted with an improper motive.
This holding leaves physicians, hospitals, and attorneys wondering about its implications for federal medical malpractice cases arising under EMTALA.
The anti-dumping legislation was enacted by Congress in 1986 in response to reports that emergency departments (EDs) at some private hospitals were refusing to treat uninsured patients or inappropriately transferring such patients to public hospitals.
The anti-dumping legislation requires that any hospital participating in Medicare provide an "appropriate medical screening examination" to any person who requests treatment from the hospital’s ED. If the screening exam finds the patient suffers from an "emergency medical condition," the hospital must stabilize the patient or effectuate a transfer of the patient pursuant to the transfer requirements of EMTALA.
Unfortunately, there is no statutory definition of "appropriate medical screening examination," an omission that has encouraged plaintiffs to bootleg claims of misdiagnoses under the anti-dumping legislation. So far, this strategy has not had a great deal of success for litigants.
Some courts, however, have found actionable claims under EMTALA in which a hospital failed to provide an adequate screening examination and, as a result, misdiagnosed the patient’s condition.
Many actions brought under EMTALA allege violations of both the screening requirement and the stabilization requirement. Although most of these cases are dismissed, some do address whether the patient was stabilized within the meaning of EMTALA, which defines "stabilize" as "to provide such medical treatment as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility."
There is no requirement of "appropriateness" under the stabilization requirement as there is under the medical screening examination requirement, a distinction the Supreme Court found significant.
Prior to the Supreme Court’s review of the Roberts v. Galen case, the Cincinnati-based Sixth Circuit Court of Appeal’s decision in Cleland v. Bronson Health Care Group (917 F. 2d 266 Sixth Circuit 1990) established what is now known as the improper motive theory.
In Cleland, the plaintiffs charged that the hospital violated EMTALA by failing to provide their son, Clair Cleland III, with an appropriate exam and by failing to stabilize him before discharge.
He was brought to the hospital suffering from abdominal cramping and vomiting, diagnosed with influenza, and discharged four hours after his arrival. Later the same day, he returned to the hospital experiencing cardiac arrest and was pronounced dead. Ultimately, it was determined that he suffered from intussusception, an intestinal condition.
In rendering a decision in Cleland, the Sixth Circuit reviewed the obligations of a hospital to provide an "appropriate" screening examination under EMTALA and crafted the "improper motive" theory. It ruled that where the screening or transfer was consistent with the screening or transfer that would have been provided to any other patient without regard to any other characteristic of the patient (such as race, national origin, gender, or ability to pay), such an exam or transfer was "appropriate," and there could be no claim under EMTALA.
In Roberts v. Galen, the Supreme Court reviewed the improper motive standard. In Roberts, the guardian claimed the patient, Wanda Johnson, was "dumped" because she could not pay her hospital bill. Initially, she was hospitalized at Humana Hospital-University of Louisville for injuries she received in a collision with a truck. Two months after her hospitalization, her condition still in a volatile state, she was transferred to Crestview Health Care Facility in Indiana. The next day her condition deteriorated significantly, and she was taken to Midwest Medical Center, where she remained for several months.
The action against Humana Hospital-University of Louisville included a claim that the transfer of the patient did not satisfy EMTALA’s transfer requirements because she was not properly stabilized at the time she was transferred to Crestview. The Court of Appeals for the Sixth Circuit agreed with the lower court’s decision that plaintiffs failed to demonstrate that the hospital acted with an improper motive. (Roberts v. Galen of Va., Inc., III F. 3d 405 Sixth Circuit 1999.)
The Supreme Court rejected the necessity of an improper motive under the EMTALA stabilization/ transfer requirement. Significantly, however, in reaching this decision, the Court did not overrule Cleland, stating that Cleland interpreted the scope of an "appropriate medical screening examination" under EMTALA’s Section 1395dd(a), whereas the Galen case focused on the stabilization and transfer requirements of Section 1395dd(b).
The Supreme Court ruled that the stabilization requirement of Section 1395dd(b) does not include a standard of "appropriateness," as does the screening examination requirement under Section 1395dd(a). Therefore, the plaintiff could recover under EMTALA without proving that the hospital acted with an improper motive.
Arguably, despite the ruling in Roberts v. Galen, the improper motive standard in Cleland still is good law in the Sixth Circuit for cases brought under EMTALA’s Section 1395dd(a), the appropriate medical screening examination requirement. Nevertheless, many health care attorneys believe the Galen case sounds a death knoll to the improper motive defense under either the medical screening obligation or the stabilization and transfer requirement.
That’s because while the Supreme Court constrained its decision to an analysis under EMTALA’s Section 1395dd(b), it questioned the Sixth Circuit’s application of the improper motive standard under EMTALA’s Section 1395dd(a). While its implications for litigants may be broad, the Supreme Court’s decision unfortunately fails to establish any guidance for hospitals as to the scope of the stabilization requirement under EMTALA.
However, in connection with the case, the Department of Health and Human Services in Washington, DC, indicated its intent to implement regulations defining the boundaries of the stabilization requirement under EMTALA.
(Editor’s note: Claudia Hinrichsen is a senior associate with Nixon, Hargrave, Devans & Doyle LLP, Long Island office, and a member of the firm’s Health Services Practice Group. She was assisted with this article by Loren Ratner, an associate with Nixon Hargrave.)