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Must I worry about EMTALA/COBRA after the patient has left the emergency room? - Roberts v. Galen of Virginia, Inc., 525 U.S. 249, 119 S.Ct. 685 (1999)

EMTALA (Emergency Medical Treatment and Active Labor Act), known by many physicians as COBRA because it was part of the one of the Consolidated Omnibus Budget Reconciliation Acts, has dramatically changed emergency department (ED) practice. All physicians who work in the ED know that they face substantial legal liability if they do not comply with EMTALA: they are subject to a $50,000 fine, they can be excluded from all federal reimbursement programs and any facility that participates in those programs, and the hospital can sue them to recoup any costs that the hospital incurs if the patient sues the hospital or any fines OIG imposes on the hospital. In Roberts v. Galen, the United States Supreme Court has broadened the reach of EMTALA, applying it to what were previously considered routine patient transfers outside of the ED.

The plaintiff in Roberts was guardian of Ms. Johnson, who was very seriously injured in an automobile accident. Johnson was admitted, through the ED, to Humana Hospital in Kentucky, where she stayed for six weeks. During this time her course was rocky and her medical condition was not stable under the terms of EMTALA. Humana then transferred her to a nursing facility across the state line in Indiana. When she arrived, her conditioned had worsened, and the nursing facility had to transfer her to Midwest Medical Center, also in Indiana. Indiana's Medicaid program refused to pay for her care because she did not meet the residency requirement. Her guardian brought this action under the EMTALA provisions that allow a patient injured by an improper transfer to sue the transferring hospital for damages.
The lower courts dismissed the action, "...holding that in order to state a claim in an EMTALA suit alleging a violation of s 1395dd(b)'s stabilization requirement, a plaintiff must show that the hospital's inappropriate stabilization resulted from an improper motive such as one involving the indigency, race, or sex of the patient." The United States Supreme Court reviewed the narrow issue of whether "improper motive" is an element of an EMTALA violation based on an allegation of improper transfer.
Plaintiff's case was based EMTALA's standard for what care the hospital must provide, once a patient has been found to have a covered condition: "such further medical examination and such treatment as may be required to stabilize the medical condition." 42 U.S.C. s 1395dd(b)(1)(A). Before this case, most hospitals and physicians evaluating patients who have been hospitalized for prolonged periods of time not worried about EMTALA because the patient's original entry into the ED was so long ago. Thinking was that as long as transfer was "appropriate" and was not, on it's face, discriminatory, it was not covered by EMTALA. This was echoed in the lower courts' requirement that the patient show some bad motive for the transfer. Looking at the plain language of EMTALA standard, however, the United States Supreme Court did not find the word "appropriate." The court concluded plaintiff need not prove that the hospital acted with a bad motive or that the transfer was discriminatory. The summary judgment was reversed and the case was remanded to further proceedings.

This case has significant implications for all physicians who are caring for patients who were initially admitted through the ED. While this case was brought against the hospital because EMTALA does give the patient a direct cause of action against the physician, the OIG could bring a proceeding against the physician who authorized the transfer of this patient, and, in theory, the hospital could claim indemnification from the physician for the cost of this lawsuit. Physicians caring for patients who were admitted through the ED must comply with the EMTALA requirements for transferring patients, irrespective of how long the patient has been hospitalized. This includes a written certification that the transfer is necessary, documentation that the receiving hospital has accepted the patients, and the medical justification for the transfer.

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