Beller v. Health & Hospital Corp. of Marion County, 703 F.3d 388 (2012)

1. Facts

1.1. Parties

1.1.1. Joshua Beller & Melissa Welch

1.1.1.1. Petitioners

1.1.2. Health & Hospital Corp. of Marion County

1.1.2.1. Respondents

1.2. What happened

1.2.1. On June 14 2011, 34 week pregnant Welch called 911 seeking emergency assistance. EMS was dispatched and discovered that Welch's water has broken and the umbilical cord was prolapsed

1.2.2. The paramedics attempted to help ease the pressure on the umbilical cord. They also contacted Welch's Obgyn office and spoke with a Nurse who suggested they take her to the nearest Emergency room for immediate treatment

1.2.3. Upon arriving at the nearest hospital,St. Francis Beech Grove. The paramedics discovered that the hospital did not have an obstetrics department, the ER doctor instead checked out Welch's vitals and recommended the transfer to another hospital - St Francis Hospital South

1.2.4. When the paramedics arrived St. Francis Hospital, the doctors there performed Caesarean surgery and delivered baby Joshua Beller

1.2.4.1. Beller had suffered hypoxia resulting in severe brain damage

1.2.4.2. The plaintifs allege that the parties involved - St. Francis Beech Grove, Wishard violated EMTALA. Instead of stabilizing the patient, they "dumped" Welch on St. Francis Hospital south. Causing delay in the delivery of the child and as a result the brain damage due to hypoxia from the umbilical cord

2. Rule of Law

2.1. Purpose behind EMTALA

2.1.1. EMTALA was enacted to address the issue of patient "dumping". A situation where uninsured patients where not given the same level of care as insured patients in emergency situations

2.1.2. This prevented hospitals from transferring patients to other health facilities or simply refusing care on the basis of none payment

2.2. EMTALA Requirements

2.2.1. In accordance to the act, hospitals are required to provide adequate care and stabilize the patient in emergency situations before they are able to transfer them to other health facilities

2.2.1.1. Hospitals are required to provide adequate screening to diagnose the cause of the emergency medical condition. The extent of the screen is adequately performed irrespective of the ability or inability to pay for the care provided

2.2.1.2. In the event of a discovery of a serious medical condition, the hospital is required to stabilize the patient. Assuring that no deterioration of the medical condition would occur in the event of a transfer from the hospital

2.2.2. The regulation was amended in 2003 to include two main stipulations for qualifications to not "come to emergency room"

2.2.2.1. One requirement is the ambulance is not deemed "come to Emergency Room" if it is operated under community-wide Emergency Medical Service Protocol that directs the ambulance to another hospital other than the hospital that owns the ambulance

2.2.2.2. Another requirement that deems the ambulance not "come to Emergency Room" is if the ambulance is operated at the direction of a physician not employed or affiliated with the hospital that owns the ambulance

3. Analysis

3.1. Plaintiff's Argument

3.1.1. The plaintiffs concede that under the 2003 amendment, they would not have been deemed "come to Emergency Room" by their presence on the ambulance.

3.1.2. The plaintiffs contend that the amendment was not a clarification but a substantial change to the definition of the regulation.

3.1.2.1. In doing so, they allege that the courts unfairly sided with the defendants in its assessment of the ruling as a clarification

3.1.2.2. The plaintiff assert that the 2003 amendment is a response to the change in which the EMS protocol was utilized and the 2003 definition simply addressed this change

3.2. Court's Position

3.2.1. The courts held that the 2003 amendment was indeed a clarification on the 2001 regulation

3.2.1.1. Thus the definition is retroactible

3.2.2. In siding with the DHHS, the court held that the amendment was a clarification to the "come to Emergency Room" clause in the first regulation

3.2.2.1. The DHHS repeated stated that the changes were in an effort to clarify the confusion from the 2001 definition.

3.2.3. The plaintiffs argument on the 2001 definition of the regulation miss the critical aspect of the case

3.2.3.1. The ambulance must be "owned and operated by the hospital" is a major determinant in the case for "come to Emergency Room".

3.2.4. The ambulance is operated by a physician not affiliated with the hospital that owns the ambulance

3.2.5. The ambulance must be operated under the community-wide Emergency Medical Service protocol, as such directing patients to hospitals other than the hospital that owns the ambulance

3.2.6. The 2003 regulation clarified the 2001 regulation and including that the individuals would not be deemed to have come to the emergency room of the hospital because the ambulance in the case of Beller v.Health & Hospital Corp of Marion County was under the operation of others.

4. Conclusion

4.1. Both definitions were deemed consistent by the courts . The holding provides guidance on what it means to be owned and under operation of a hospital how it differs in the event of two extenuation factors - Community-wide EMS protocol and unaffiliated physician leadership by a physician of ambulance company.

5. Issue before the court

5.1. Whether the defendants violated the Emergency Medical Treatment and Active Labor Act (“EMTALA”), by failing to stabilize Melissa Welch and her minor son, Joshua Beller, during an emergency medical situation.

6. Importance

6.1. The ruling on the case of Beller v. Health & Hospital Corp. of Marion County, 703 F.3d 388 (2012) has provided health care facilities with protection from liabilities that ensue in the event of a law suit as a result of the "come to emergency room" clause in EMTALA

6.2. The 2003 change in regulation clarifies the definition of "come to Emergency room" and addresses the ambiguity from the 2001 definition on what the hospital's role in the use of its ambulance for the community-wide EMS services

7. Impact

7.1. Bowen v. Georgetown University Hospital, 488 U.S. 204, 208–09, 109 S.Ct. 468, 102 L.Ed.2d 493 (1988)

7.1.1. The Supreme Court held that unless express authority was provided by Congress, an agency is not authorized to make retroactive laws except in the event explicit language is used in clarifying the result.

7.2. Middleton v. City of Chicago, 578 F.3d 655, 633 (7th Cir.2009)

7.2.1. Congress enacted USERRA nearly four years after enacting subsection 1658, and it did not include in USERRA a statute of limitations. As such, USERRA was deemed subject to subsection 1658. Congress, recognizing that USERRA did not discuss the federal statute of limitations, The legislature, however, stopped short of bestowing retroactive effect upon the new law.

8. Influence

8.1. As a result of the holding, patients must prove they arrived at Emergency department

8.1.1. Come to Emergency Room definition as clarified by 2003 amendment removed legal exposure from the hospitals that own ambulances used in EMS protocol