The University of Chicago has emerged at the center of the EMTALA storm arising from large urban hospitals adopting policies to try to drive uninsured “less urgent” patients out of the Emergency Department to reduce costs in a slightly modified version of policies that were referred to as “Triage Out” in the early era of EMTALA.

Although most hospitals had abandoned “Triage Out” due to the high rate of EMTALA violations cited by CMS, the current economic situation has seen a resurgence of the practice in major urban hospitals in Colorado, Texas, and now Chicago.  

The University of Chicago plan called its “Urban Health Initiative” hit the headlines recently with reports of a case where a child had his lip virtually ripped off by a pit bull.  According to published reports in the Chicago Tribune, the child was not seen for up to 3 hours after presenting, and then was given a pain pill and discharged to seek care elsewhere.  The child was admitted for emergency surgery at Cook County’s Stroeger Hospital, which is a charity facility.  The child reportedly was insured under Illinois Public Aid.

Facts in Controversy

The University of Chicago defended its actions in the case by saying that it provided its standard exam in timely fashion, and medical personnel determined that it would not be appropriate to close the wound at the time.  They state that they dressed the wound and discharged the patient to seek care in a more appropriate and less costly setting.  The patient’s mother denies the hospital version and indicated that they were simply told to get care elsewhere, and the mother had to bandage the wound.

Several political issues appear to further raise concerns about the practice. The State of Illinois running substantially behind on Medicaid payments to healthcare providers that are forcing many hospitals in the state to law off personnel., and the University of Chicago has announced that it feels 40% of the 80,000 ED visits are not necessary.  This figure raises questions about the hospital’s intent at avoiding care to the needy neighborhood surrounding the hospital, as the 40% rate is substantially higher than most estimates for ED use in other facilities.  The program replaces a prior practice of counseling patients on proper sources for care following ED treatment.   

The prior practice involved former UC attorney Michelle Obama, and the unknown extent of her involvement in the new practice raises political concern about what direction President Obama’s administration is likely to take on EMTALA enforcement, payment for emergency medical care, and healthcare in general.

ACEP Speaks Out

In an unprecedented move, the American College of Emergency Physicians president – apparently concerned about the risk of more hospitals adopting the UC model and denying care reminiscent of the “Dumping” practices that gave rise to the EMTALA laws – blasted the practice as “dangerously close” to breaking the law.    The UC unabashedly states that its policy is to move out of emergency care and lower acuity care and to focus more on high revenue elective procedures.  Requests have been made to Congress to conduct an investigation into the UC situation.

Whether the UC “dumped” this child or not comes down to documentation, evidence, and facts, but there is little doubt that their policy has the strong propensity to deny care and move patients contrary to the spirit, and perhaps the letter, of EMTALA.  Their express purpose is get 32,000 patients out of the ED and send them elsewhere.  EMTALA, however, has the inherent expectation that everyone will get the same level of assessment and, where they might suffer deterioration or disability if left untreated, care must be rendered at the initial hospital

Will We Return To The Good Old Days of Dumping?

Tough questions need to be asked in this case, because of the prospect of this model of care spreading and because of the implication that care may have been denied because of the patient’s means or ability to pay.  It raises a legitimate specter of hospitals dumping government insured patients right at a time where there is a prospect of a major revamping of the healthcare system that could result in massive numbers of people being on governmental insurance programs.  

The sincerity of UC in their concern for providing appropriate care also becomes suspect, like so many other protestations of innocence coming from Illinois lately, because they don’t come to this point without prior experience with EMTALA.  They have been cited for EMTALA violations and were the object of a major legal case involving EMTALA that ultimately resulted in the EMTALA “ambulance rule” requiring hospital owned ambulances to transport patients to their own hospital.

The UC was one of the early hospitals to get cited under EMTALA when they transported a gunshot victim in emergency condition to Cook County hospital without complying with EMTALA.  As recently as 2004, they were fined for another violation.   

Unusual Prior Outcome

In the Johnson v. University of Chicago case, plaintiffs alleged that the hospital turned away an infant in respiratory arrest just blocks from the hospital and sent the child to another hospital several miles across town.  While the 7th Circuit Court of Appeals finally decided to dismiss the case after 3 separate opinions, finding that there was no duty to accept ambulance cases who were not yet on hospital grounds. The majority rule in recent cases from other Circuits holds to the contrary unless the ED is on formal diversion.

Wait And See

At this point, it is my recommendation that hospitals NOT attempt to move patients out of ED’s in a UC type approach.  I believe it is very prone to produce EMTALA violations and lots of malpractice and EMTALA lawsuits. It also leaves a very bad taste in the community’s mouth that can have severe consequences for hospitals in the coming years.

I limit my recommendation to  “at this point” because the future of government action on healthcare is totally uncertain.  We also need to wait in judging the impact of the  UC policy on any fact finding determinations that might be forthcoming, if CMS or Congress does actually step into investigate.  Being a life-long Illinois resident, I am not holding my breath, but ethics and transparency would help guide hospitals considering following UC into these controversial waters

Tags: EMTALA, refusal of care, Triage Out, University of Chicago