Special report on patient care. HCFA finally issues patient-dumping regulations

EMTALA has always been an especially worrisome law for providers because its requirements are both sweeping and vague, with potentially drastic penalties for violations. The new regulations remove only some of the law's vagueness. As with previous EMTALA amendments, all United States hospitals, as well as emergency department physicians and other doctors who see patients in the emergency department, should carefully review their internal policies regarding patient ++ transfers in light of the new regulations. For example, hospitals must have an internal policy for following up on suspicious transfers, as failure to detect an inappropriate transfer can now potentially result in a Medicare decertification action. Also, hospitals with specialized services (e.g., burn units or shock-trauma units) should review their policies on receiving transfer patients in light of the greater specificity of the new regulations. Finally, because of the confusing new requirements regarding ambulance services, all hospitals should review their relationships with and policies regarding, ambulance services and ambulance diversion.     

Special report on labor and employment. The Department of Labor issues final regulations for the federal Family and Medical Leave Act

The FMLA is a complicated and comprehensive regulatory scheme, and it is impossible to review any but the most basic provisions in this article. The final regulations provide very detailed guidance on such issues as benefits continuation, reinstatement rights, notice requirements, and enforcement measures. Personnel policies and practices must be revised to be consistent with these final regulations, and care must be taken that leave policies do not restrict rights under the FMLA or unintentionally create expanded leave rights. In complying with the FMLA, employers must also keep in mind that there are complex interplays between the federal FMLA, state laws that provide family and medical leave, the Americans with Disabilities Act, and state workers' compensation laws, that can require expert advice depending on the particular circumstances.     

Special report on patient care. New OBRA 1990 requirements regarding advance directives

The provisions of OBRA 1990 regarding advance directives reflect a heightened awareness in Congress of the need to recognize individual rights and preferences in the provision of health care. In the wake of recent decisions such as Cruzan v. Director, Missouri Department of Health, 110 S. Ct. 2841 (1990) (see Newsletter, Vol. 5, No. 9, September 1990, at 12), holding that state law governs the right of a surrogate to order the discontinuation of medical treatment for an incompetent patient, it is likely to remain true for the foreseeable future that differing state laws on the subject of advance directives will create confusion for some patients, particularly those unaware of the laws of their state, those living near the border between two states, and those traveling between states for medical treatment. For such patients, the provisions of OBRA 1990 may help to ensure that state laws governing advance health care decisions are explained at the time of treatment.     

Special report on health care delivery systems. Final regulations implement Clinical Laboratory Improvement Amendments of 1988

The primary purpose of CLIA and the Regulations is to strengthen federal oversight of clinical laboratories to ensure that test results are accurate and reliable. The new law and the Regulations create a national unified certification and enforcement system that affects virtually every laboratory in the country. Thus, all laboratories and health care providers with laboratory components that may be affected should carefully review the Regulations and prepare to comply with them well in advance of their September 1, 1992 implementation date.     

Special report on health care reform. ERISA preemption, Traveler's and health care reform

Although S. 308 reportedly has some bipartisan support, its passage is by no means certain. ERISA has for years provided employers with the freedom to design their own benefit plans without state interference, as well as the ability to operate such plans in a uniform manner throughout the country. large employers are thus not likely to cede the advantages of ERISA preemption without a battle. When strong business interests are pitted against the states' equally strong interests in enacting health care reforms, the outcome cannot be predicted.     

The new EMTALA regulations and the on-call physician shortage: in defense of the regulations

This Article examines the new Emergency Medical Treatment and Labor Act (EMTALA) regulations, focusing on the on-call provisions, in light of the practical realities of the on-call physician shortage. It provides an historical account of issues surrounding the delivery of emergency care by on-call physicians and the legal background of EMTALA insofar as it relates to on-call physicians. Ultimately, the author concludes that, although the current shortage of on-call physicians has caused hospitals to anticipate EMTALA liability and advocate for more specific regulations, a closer look reveals that hospitals' fears are overstated. As long as hospitals have proper procedures in place, the new regulations will not put them in violation of EMTALA.     

Special report on liability and insurance. An update on assignment of patient benefits under ERISA

While the holdings in Davidowitz and Arkansas Blue Cross & Blue Shield arose in different contexts, they both reflect the courts' increasing willingness to consider the importance of cost containment in the health insurance arena, even though patient accessibility to health care may be restricted as a result. If the holding in Davidowitz is not successfully appealed, providers may need legislative relief in order to retain their ability to take valid assignments of patient claims for payment from ERISA plans. It is uncertain whether such legislation can be sought at the state level or must instead come from Congress due to ERISA preemption of state legislation. Clearly, the district court decision on remand in Arkansas Blue Cross & Blue Shield will be closely watched for any light it may shed on this question. On a pragmatic note, providers who have not entered into "participation" agreements with insurers or other private payors may now have a greater incentive to do so, and "nonparticipating" providers who continue to obtain assignments from patients in order to collect directly from insurers or other private payors should determine on a case-by-case basis whether the source of the patient's benefits is a group health plan--which is likely to fall under ERISA and may contain nonassignment provisions--or some other form of coverage. For an additional perspective on insurers' responses to copayment waivers, see Newsletter, Vol. 6, No. 10, October 1991, at 7.     

Special report on medical staff relationships. Handling "impaired" health care professionals

Applying the doctrine of corporate negligence, courts will, in appropriate circumstances, deem hospitals and other institutional health care providers responsible for the quality of patient care in their institutions and for the consequences of negligent physician performance that could have been discovered and prevented. See, e.g., Darling v. Charleston Community Memorial Hosp., 33 Ill. 2d 326 (1965), cert, denied, 383 U.S. 946 (1966); Johnson v. Misericordia Community Hosp., 99 Wis. 2d 709 (1981); Elam v. College Park Hosp., 132 Cal. App. 3d 332 (1982). In such a climate, and with Data Bank reporting now a reality, neither institutional providers nor health care professionals on their medical staffs can afford to ignore problems of practitioner impairment. Recognizing this reality, some state laws now mandate an organized approach--such as the establishment of an impaired practitioners committee--to problems of professional impairment. However, whether state-mandated or not, providers must have policies and procedures in place to insure not only that impaired professionals are referred to available treatment programs, but that they fully participate in and complete such programs, and achieve rehabilitation, before they return to practice at the institution. The earlier detection and treatment are initiated, preferably before peer review action becomes necessary, the better for patients, institutions, and practitioners themselves.