No relief; EMTALA doesn’t cover medical malpractice claims

A U.S. District Court in Alabama has dismissed a claim brought by a patient against the Health Care Authority of the City of Huntsville (the Hospital). The patient, a woman who came to the emergency room, alleged the hospital violated EMTALA by failing to conduct an appropriate screening exam and stabilize her after her admission to the hospital. The hospital moved to dismiss the lawsuit claiming they screened her appropriately and stabilized her after she arrived. The court held that the hospital met EMTALA requirements and granted motion to dismiss under Federal Rules of Civil Procedure 12(b)(6) (Baker v Health Care Authority of the City of Huntsville, July 9, 2019, Kallon, A.).

The court looked to the EMTALA requirements to determine whether the patient stated a claim for which relief could be granted. The court noted that congress enacted EMTALA to prevent hospitals from turning away or transferring indigent patients without evaluation or treatment. The court noted that to prevail on the patients EMTALA claim she must plead facts showing that the hospital violated the appropriate medical screening or stabilization requirements.

Screening requirement

EMTALA requires that when a person goes to the emergency room for an exam or treatment, the hospital must provide for an appropriate medical screening exam. The screening must be within the capability of the emergency room to determine whether or not an emergency medical condition exists. It also requires that indigent patients receive similar care to anyone else that would be screened in the emergency room with similar symptoms.

Under the facts of this case, the woman was given four screenings within an hour of arrival in the emergency room. She was diagnosed with a hypertensive emergency and admitted to the hospital. Several hours later she was examined again and properly diagnosed with a stroke. The woman argues that because she was not diagnosed with a stroke earlier, the hospital did not conduct a proper screening. The woman did not allege any facts to show that she was screened differently from any other patient. The court held that as long as the hospital screened her similarly to any other patient with the same symptoms there is no liability under EMTALA.

Stabilization requirement

Under EMTALA the stabilization requirement has to do with transferring the patient to another facility. The statute requires that the hospital treat the emergency condition as necessary to assure with reasonable medical probability that no material deterioration of the condition occurs during transfer of the patient. The court found that the EMTALA obligation to stabilize ends when the patient is admitted to the hospital and not transferred. In this case the woman was admitted to the Huntsville Hospital and therefore the woman would have had to plead facts to show that the hospital admitted her with intention to subterfuge to avoid EMTALA liability. Since she did not allege any facts to support that allegation the court holds that she has not alleged a plausible claim for violations of EMTALA’s stabilization requirement.

Holding

The court found that the woman’s allegations against the hospital for failure to provide her with timely and necessary treatment may support a malpractice claim but do not fall under a violation of the EMTALA statute. The woman would have had to show that the hospital treated her differently than other patients who presented with similar symptoms. The claim was dismissed under Rule 12(b)(6) and the court declined to exercise supplemental jurisdiction over her state law claims.

Alabama wants to push back Medicaid managed care demonstration

Alabama wants to delay the transition of its Medicaid program to a managed care model. In a letter to CMS, the state requested CMS’ acceptance of amended terms for the state’s Medicaid transition demonstration. The request makes no substantive changes to the program. Its purpose is to allow the state more time to appropriate funding and complete readiness activities.

Waiver

In 2016, CMS approved a Section 1115 waiver permitting Alabama to transition its Medicaid program to a managed care model relying on regional care organizations (RCOs). Under the waiver, Alabama was granted almost $750 million to start and improve its RCO program. However, even with the federal funds, the state says it does not have the necessary funds to get the program up and running.

Delay

The state is requesting to change the demonstration time period from April 1, 2016, through March 31, 2021 to April 1, 2017, through March 31, 2022. The change is driven primarily by financial concerns. Alabama officials say the delay allows more time for the appropriation of additional state funding and completion of readiness activities. Finally, the letter indicated the delay would also help the state meet broader demonstration goals: addressing fragmentation in health care delivery, improving chronic disease prevention and management, improving access and care coordination, improving birth outcomes, and enhancing the financial efficiency of the health care delivery system.

Highlight on Alabama: Class action against state alleges inadequate prison mental health care

Focus on the issue of accessibility to quality mental health care has been growing in recent years, and the state of Alabama is facing intense scrutiny for the possible failure to treat mentally ill inmates. A federal trial began on December 5, 2016, in which dozens of inmates are expected to testify.

This trial is one part of a larger suit filed by the Southern Poverty Law Center (SPLC) in 2014 alleging that overall, medical care in the state’s prisons is below constitutional standards. Claims that the Department of Corrections (DOC) failed to accommodate prisoners with physical disabilities were previously settled, with the DOC agreeing to improve its facilities.

U.S. District Judge Myron Thompson granted class action status to the mental health portion of the case in November 2016,  noting that the failure to provide funding for staff creates an Eighth Amendment violation, even if this is caused by a lack of available money.

The claims currently being heard allege that the mental health care, provided through the contractor MHM Correctional Services, fails to provide enough providers to offer care, including psychiatrists, psychologists, and nurses. Additionally, the lack of security staff causes interruptions in care. This results in failing to identify mentally ill inmates and properly diagnose the severity of illness in those who are identified. These issues have led to a failure to prescribe medication, manage side effects, offer adequate counseling, and properly monitor and treat inmates who are suicidal and self harm.

According to a local news report, the first inmate witness had been in prison for six years and is currently at the Donaldson Correctional Facility. He testified that he had physical and mental illnesses and was prone to self harm, but he only sees mental health staff approximately every two months for sessions lasting about five or 10 minutes.

SPLC stated that other expected witnesses include a Dr. Kathryn Burns, a mental health expert who has inspected nine Alabama prisons and their mental health procedures.

This suit is not the only attention Alabama’s prisons are currently receiving. In October 2016, the Department of Justice began a statewide investigation into the conditions in Alabama’s prisons. This investigation is to focus on efforts to protect prisoners from abuse and excessive force at the hands of other prisoners or correctional offers, as well as the provision of sanitary, secure, and safe living conditions.

Update on Controversies in Medicaid Managed Care

Since October 2012, Kentucky’s Medicaid officials have been on notice that Kentucky Spirit, the Medicaid managed care organization  (MCO) owned by Centene, was terminating its contract at the beginning of July. As we reported in June, the Circuit Court in Franklin County ruled that neither party had breached the contract yet. That meant that when Kentucky Spirit terminated, it would breach the contract, and, therefore,  would be liable to the state for liquidated, or predetermined, damages. Kentucky Spirit appealed.

As the termination date approached, state officials returned to court seeking an order to keep the MCO from leaving. On June 26, 2013, Judge Thomas Wingate denied the state’s request. For one thing, the appeal ended his jurisdiction over the matter. But, he added, the court had repeatedly cautioned the state to prepare for the termination, and its lack of preparation did not justify  the extraordinary remedy of an injunction.

State officials asked the Kentucky Court of Appeals for an emergency order to compel Kentucky Spirit to stay on the job through August. On Monday, July 1, 2013, Chief Appeals Court Judge Glenn Acree denied the request for the same reasons. The state had ample time to prepare, and it should not need another two months to transition the MCO’s 124,000 members to one of the two remaining plans. Kentucky Spirit  ceased offering services to beneficiaries at 12:01 a.m. Saturday, July 6, 2013, although about 100 employees remain to help patients and providers with the transition.

Developments in Other States

Mississippi also moved to Medicaid managed care in 2012. In June 2013, Dr. Tim Alford, president of the Mississippi Academy of Family Physicians, met with Governor Phil Bryant  and testified before a state House committee. Dr. Alford called the managed care program “wildly unpopular” and stated that it was disruptive to the physician-patient relationship.

KanCare has been operational about six months now. So far, there have been few complaints. However, owners of small pharmacies say that the MCOs’ maximum allowable cost formula for some prescription drugs doesn’t cover their costs.

Now Alabama is beginning the latest adventure in Medicaid managed care contracting.