Beller v. Health and Hospital Corp. of Marion County, Indiana d/b/a Wishard Memorial Hospital 703...
1. Issues Before the Court:
1.1. Whether or not the plaintiffs had "come to the emergency room" of Wishard Hospital when they were transported in the Wishard Ambulance
1.2. Which definition applies to the case:
1.2.1. The 2001 regulation:
1.2.1.1. 42 C.F.R. SS 489.24(b)
1.2.1.2. "Property" of the hospital includes ambulances owned and operated by the hospital even if the ambulance is not on hospital grounds.
1.2.2. The 2003 amendment:
1.2.2.1. That a person is not on the property of the hospital if the ambulance is operated under community wide EMS protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance.
2. Rule of Law:
2.1. EMTALA
2.1.1. Emergency Medical Treatment and Labor Act
2.1.1.1. The philosophy that healthcare at the time of an emergency is a moral right and must be provided regardless of the patient's ability to pay.
2.1.1.1.1. Prevents "patient dumping"
2.1.1.2. Requires a medical screening
2.1.1.3. Must stabilize emergency medical conditions a patient has prior to transferring
2.1.1.4. Applies to all patients regardless of ability to pay
2.1.1.5. Applies to all hospitals participating in Medicare
2.1.2. Case References leading to EMTALA:
2.1.2.1. Childs v. Weis
2.1.2.1.1. Early common law
2.1.2.2. Williams v. Hospital Authority of Hall County
2.1.2.3. Stanturf v. Sipes
2.1.2.4. Guerrero v. Copper Queen Hospital
2.1.2.5. Thompson v. Sun City Community Hospital, Inc.
3. Analysis
3.1. Ms. Welch feels her condition should have been stabilized by Wishard Hospital since she was transported by their ambulance when she initially called 911
3.1.1. She claims she was on hospital property because the ambulance was owned and operated by Wishard Hopsital under the 2001 regulation
3.1.1.1. The acting regulation when the incident occurred.
3.1.2. Claiming an EMTALA violation
3.2. Since the case was brought to the court after the 2003 amendment of that changed the wording of the regulation
3.2.1. Could the 2001 regulation be retroactively applied?
3.2.1.1. In a 1988 Supreme Court case, an administrative agency may no promulgate retroactive rules unless Congress has provided the agency with the expressed authority to do so
3.2.2. Did the 2003 amendment create substantive changes or was it merely a clarification of the meaning of that phrase?
3.2.2.1. The District Court held it was a clarification
3.2.2.2. Must give "great weight" to the intent of the promulgating agency
3.2.2.3. The DHHS considered the amendment a clarification of the definition "comes to the hospital"
3.2.2.3.1. Repeatedly stated the changes were clarifications
3.3. The district court found the DHHS intent was to provide clarification to the 2001 regulation to alleviate confusion surrounding the hospital owned ambulances operating under the EMS protocols
3.3.1. The appellate court upheld this reasoning.
3.4. The DHHS clarified that EMTALA does not apply when the hospital owned ambulance is operating under communitywide protocols that require it to transport an individual to a hospital other than the hospital that owns it
3.4.1. The appellate court agreed that the statements are unambiguous and the plaintiffs ignored its plain language.
3.4.1.1. The plaintiffs statement that a person comes to the hospital ignores the second qualifier, which is the ambulance must be operated by the hospital
3.4.1.1.1. Narrowing the law by the example of "Clarifying Regulation"
4. Conclusion:
4.1. The appellate court affirmed the district court's ruling in summary judgment.
4.1.1. The ambulance must be both "owned" and "operated" by the hospital to be considered "hospital property".
5. Facts of the Case:
5.1. Parties:
5.1.1. Plaintiffs: Melissa Welch and Joshua Beller
5.1.2. Defendants: Health and Hospital Corporation of Marion County, Indiana d/b/a Wishard Memorial Hospital
5.2. June 14, 2001: Melissa Welch called 911 for emergency treatment
5.2.1. Wishard ambulance responded
5.2.2. Welch was 34 weeks pregnant
5.2.3. Paramedics found Ms. Welch's water had broke and presented with a prolapse cord
5.2.3.1. A prolapsed cord is a serious medical emergency in which blood flow and oxygen can be cut off from the fetus due to pressure on the cord.
5.2.3.2. The paramedics were unable to relieve the pressure and took Ms. Welch to the nearest facility.
5.2.4. Ms. Welch was transported to St. Francis Beech Grove emergency room
5.2.4.1. Beech Grove did not have obstetrics coverage
5.2.4.2. The physician evaluated Ms. Welch and arranged for transportation by the Wishard ambulance to St. Francis Hospital South
5.2.5. At St. Francis Hospital South, Joshua Beller was born via caesarean section.
5.2.5.1. Joshua Beller had suffered significant hypoxia due to the prolapsed cord and suffered severe brain damage.
5.2.6. Ms. Welch sued Wishard Hospital stating they violated EMTALA by transferring Joshua to Beech Grove instead of stabilizing him and that the failure to do so resulted in his permanent injuries.
5.3. Procedural History
5.3.1. Ms. Melissa Welch files suit against Wishard Memorial Hospital
5.3.2. District Court granted summary judgement to the defendant (Wishard)
5.3.3. Plaintiffs appealed
5.3.4. The appellate court, in summary judgement, affirmed the district courts ruling
6. Impact:
6.1. Set the precedence to clearly interpret the definition of DHHS's regulation
6.1.1. Owned or Operated v. Owned and Operated
7. Importance:
7.1. This ruling set the definitions of the DHHS's 2001 regulation and the amendment in 2003 whether or not a person/patient on an ambulance owned by a hospital is on said hospital's property if the ambulance is operating under communitywide EMS protocols.
7.1.1. In West Virginia, an EMS organization is owned by a Health System/Hospital but must follow the statewide protocols. Each agency in the state follows the same protocols regardless of the organization.
7.1.2. In Georgia, each agency runs under their own set of protocols. In one county alone (Fulton), there are at least 3 different sets of protocols for each agency operating in that county.
7.1.2.1. Grady EMS, a hospital owned and operated agency, follows protocols set by the hospital's medical director in accordance with state law.
7.1.2.1.1. By interpretation, Grady EMS ambulances are on hospital property and EMTALA applies.
8. Influence:
8.1. Emergency Departments seeing an influx of patients who use the department as primary care centers because they can not be turned away.
8.1.1. This has lead to the overcrowding of emergency departments leading to high turnover rates of employees.
8.1.2. Emergency departments are also seeing a rise in the abuse of emergency departments by the homeless populations in their city.
8.1.2.1. Using the ED as a shelter during unfavorable weather and to receive food during their stay.
8.2. Emergency Medical Services requiring a physician to approve a refusal of care in the field.
8.2.1. Paramedics will call a medical control number at their home hospital to have an MD speak with a patient prior to getting a signed, informed refusal.
8.2.1.1. Indirect medical screening