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ACEP condemns Rep. Diane Black's suggestion to scrap EMTALA

Emergency room overcrowding is caused by lack of access to care, and the focus should be there, ACEP says.

Beth Jones Sanborn, Managing Editor

Republican Tennessee Representative and House Budget chair Diane Black, is making waves after suggesting that EMTALA, the law requiring that doctors treat any and all patients that present in their ER, is driving up healthcare costs and should be repealed.

Black, who has a background as an ER nurse, recently made an appearance on MSNBC and made the assertion regarding EMTALA during her discussion with anchor Chuck Todd. The remarks were made amidst a discussion on the so-far failed efforts of Republicans to repeal the Affordable Care Act. Black said she wished Trump would write an executive order repealing the individual and employer mandates so they can let the "market work," when Todd brought up that the healthcare market doesn't work and cited EMTALA, saying doctors are required to treat everyone who comes into an emergency room and are essentially being forced to subsidize free healthcare that no one pays for in ER.

[Also: Nearly half of medical care comes from emergency rooms, study shows]

Black then cited her background as an ER nurse and lamented the law, saying it took away their ability to decide that an emergency room is not the proper place for a non-emergent patient to get treatment.

"I would get rid of a law that says you are not allowed as a healthcare professional to make that decision about whether someone can be appropriately treated the next day or at a walk-in clinic or at their doctor. But we must treat everybody that walks in whether you've had a sore throat for a week we must see them. and that crowds the emergency room. It drives the costs of emergencies up. So yeah if someone comes in from an auto accident I don't want to ask them if they have insurance or not, I'm gonna take care of them. But what it did was crowd my emergency room where I worked and it disallowed me from using my good judgment skills of which I was trained to do and which doctors are as well."

[Also: Emergency departments, physicians forced to re-examine philosophies, operations as elderly patients present challenges]

Howard Mell, a practicing emergency physician in the Chicago area and spokesperson for American College of Emergency Physicians unequivocally rejected the notion that EMTALA should be repealed, saying that in the days before EMTALA, emergency physicians were "kind of in a weird spot" because their organizations would demand that they prove the patient's ability to pay before treating them, even in the face of serious illness or injury, or even labor. He cited cases where mothers lost babies because they were transferred hours away to a charity hospital, sometimes based on even just an assumption that they couldn't pay. EMTALA was a way to ensure patient safety wasn't compromised like that again.

He cited recent research that showed about 48 percent of all medical care in the U.S. is provided by ERs, and the law is key to emergency medicine.

"Most of my colleagues who have gone into emerg medicine since the law was passed did so because they want to care for everybody. I love the fact that I don't worry about the business of healthcare. I see patients. You come in, you need help. I don't care if you're a prince or a pauper. I don't care whether you have an outstanding bill or whether you made a donation to build the hospital. I take care of you."

[Also: Only 3.3% of emergency room visits are 'avoidable,' study says]

He also said emergency medicine accounts for only 2 to 3 percent of the national healthcare budget on an annualized basis. "So when you're talking about driving up healthcare costs, even for the sake of argument if we could save one third of all emergency costs by repealing EMTALA, which is a ridiculous assertion, we've saved all of one percent of healthcare spending. That's budget dust," Mell said.

He also cited statistics from the CDC that show only 4 percent of patients don't meet the criteria for some form of emergency care, rejecting the notion that ERs are crowded with people who don't need to be there.

The real issue, he said, is access to care. When people make the assertion that the uninsured or impoverished are clogging our ERs, which he believes is what Black is saying, she's not wrong but it's not that they aren't emergent.

He gave an example of a patient who is working, has insurance and is doing very well, but then loses their job and must go on Medicaid. The patient can't find a Medicaid doctor and is dropped from their current insurance due to the job loss. They have lost access to crucial medications, like diabetes, asthma or blood pressure medications, and eventually suffer a health event like an asthma attack or stroke. 

"It's unfortunate that 40 percent of the care in the U.S. has become episodic emergency care. We are literally living, as a nation, asthma attack to asthma attack instead of treating asthma. The same goes for high blood pressure heart attacks and strokes."

He said the public misunderstands articles that show EDs are providing much of the care in the U.S., which can conjure an image like running an immunization clinic at 3 a.m. for the sake of convenience. What's really happening, he said, is all of the preventative care and day to day care that could stop lots of crisis emergency department visits simply isn't being provided.

"If Representative Black wants to save money in the emergency departments, we should put much more of a focus on making sure people have access to day to day care. That's how you cut down the number of emergencies we have...If we can prevent a heart attack or a stroke, that's how you save money in healthcare."

And when it comes to those non-emergent, "catch and release" visits, Mell said he welcomes them because they actually take up very little of his time, whether it's a stubbed toe or someone who can't get to primary care physician but needs a sick note for work. 

"It's the patient who is having chest pain, whose blood glucose is 400 bp is 200/100 and they haven't had any anti-cholesterol medicine for a year, and because they are poor they have been eating junk and fast food because it is the only source in the food desert that they live in. That patient is going to take me a long time."

Had they had access to care or medicine, they wouldn't be there in the first place. Mell said he'd even rather have them come in to the ER and get their meds, and take up 5 mins of his time, rather than then come in with a stroke or heart attack.

"They are going to limp along between crises that we could have prevented with better access to care."

Twitter: @BethJSanborn
Email the writer: beth.sanborn@himssmedia.com

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