1. Facts
1.1. Parties
1.1.1. Plaintiffs: Melissa Welch & Joshua Beller
1.1.2. Defendant: Health and Hospital Corp. of Marion Coounty d/b/a Wishard Memorial Hospital
1.2. What Happened
1.2.1. June 14, 2001
1.2.1.1. Melissa Welch, mother of Beller, called 911
1.2.1.1.1. Current State: 34 Weeks Pregnant
1.2.1.2. Paramedics arrived and determined Welch's water had broken and the umbilical cord had dropped ahead of the baby (prolapsed umbilical cord).
1.2.1.2.1. Ambulance owned by Wishard
1.2.1.3. Paramedics consulted with nurse at Welch's OB office
1.2.1.3.1. Transport immediately to nearest hospital
1.2.1.4. Paramedics consulted with St. Francis Beech Grove ER and moved to transport Welch there.
1.2.1.4.1. Physician examined Welch and decided to transfer her to St. Francis Hospital South
1.2.1.5. St. Francis Hospital South delivered Beller via c-section
1.2.1.5.1. By then Beller had suffered from deprivation of oxygen to his brain (hypoxia).
1.3. Procedural History
1.3.1. Beller sued Wishard Memorial Hospital for violating EMTALA
1.3.1.1. Reason: Failure to stabilize Welch and Beller prior to transfer
1.3.1.1.1. Outcome: District Court ruled in favor of Wishard
1.3.2. Plaintiff appealed to District Court
1.3.2.1. Outcome: District Court's ruling was upheld
2. Analysis / Application
2.1. How did each side present the Rule?
2.1.1. Plaintiffs claimed Defendant violated EMTALA
2.1.1.1. Did not stabilize Plaintiffs prior to transferring
2.1.1.2. Argued ambulance is "hospital property" therefore making Wishard liable for EMTALA care
2.1.1.2.1. According to 2001 definition, as incident occurred prior to amendment.
2.1.1.2.2. Argued 2003 amendment was not clearly defined as "clarification" of the law.
2.1.2. Wishard disputed claim.
2.1.2.1. Ambulance was operating under EMS protocols
2.1.2.1.1. Plaintiffs and Defendants agreed that under the 2003 definition, the Plaintiffs would not have been considered as "coming to the emergency room"
2.2. How did the Court apply the Rule in making its decision?
2.2.1. The Department of Health and Human Services (DHHS) repeatedly stated in their "Final Rule" implementing the 2003 amendment as a clarification to the scope of the 2001 definition.
2.2.1.1. Court also quoted specific titled of the Final Rule: "Clarifying Policies Related to the Responsibilities of Medicare - Participating Hospitals in Treating Individuals with Emergency Medical Conditions."
2.2.1.1.1. Court declared this, and additional references from the original proposal, as unmistakable clarifications.
2.3. Did the court expand, reinterpret, or narrow the law to reach its conclusion?
2.3.1. Narrowed the law by clarifying that the amendment was merely a clarification of the law, not a change.
2.4. What facts were compelling to the court in its analysis?
2.4.1. The DHHS's proposal document was the most valued resource in the court's eyes.
2.4.1.1. The court was able to able to definitively rule in favor of the defendant because of the plaintiffs' exclusive focus on the ambulance's ownership by Wishard.
3. Rule of Law
3.1. Emergency Medical Treatment and Active Labor Act (EMTALA)
3.1.1. Purpose: In response to hospital concerns of patient "dumping" - transferring or refusing to treat patients who appear to be unable to pay for services rendered.
3.1.2. Requirements: ERs must provide any person arriving on hospital grounds and in need of emergency treatment care with the acceptable standard to assess and stabilize them regardless of ability to pay.
3.1.3. Specific Focus: Focused on definition of a person who is deemed as having "come to the emergency room."
3.1.3.1. 2001 Definition: Individual is on hospital property, including ambulances owned and operated by the hospital, even when not on hospital grounds.
3.1.3.2. 2003 Amendment: However, this does not apply is the ambulance is operating under communitywide EMS protocols that direct transport of the individual to a hospital other than the one that owns the ambulance.
4. Issue
4.1. Did the Plaintiff technically "come to the emergency room" of Wishard when they were transported via their ambulance?
5. Impact
5.1. Hatzell et al v. Health and Hospital Corp. Marion County
5.1.1. This case, involving the same hospital system, references the Beller v. Health and Hospital Corp. of Marion County case to support the proper application of EMTALA, in regards to medical screening, by the defendant.
5.2. The Chattanooga-Hamilton County Hospital Authority v. UnitedHealthcare Plan of the River Valley, Inc.
5.2.1. This case references Beller v. Health & Hospital Corp. of Marion County to further clarify EMTALA. As the hospital was disputing the lack of proper reimbursement by the payer. The payer was disputing the hospital's rights to skip the proper state regulations in pursuit of this claim, e.g. TennCare regulations, Uniform Administrative Procedures Act.
6. Conclusion
6.1. The judgment of the Court was upheld in regards to EMTALA's 2001 definition and 2003 clarification of "comes to the emergency room."
6.1.1. Although Wishard owned and operated the ambulance of the Plaintiffs because they were operating under the community's standard EMS protocol, they were not liable for the requirements under EMTALA.
7. Importance
7.1. The value of this case's decision is its distinction between "hospital property" and standards of care, as well as, application of law.
7.1.1. EMS protocol was elevated to a higher standard of care than the operations of the hospital system in ownership of the ambulance.
7.1.2. Validated the right to retroactively apply the law when it is deemed a "clarification" of one already established.
8. Influence
8.1. A major influence as a result of cases such as this is the practice of specialized hospital ratings or specialties.
8.1.1. For example, trauma ratings are established to properly direct EMS patient flows within a territory and support patients getting the right care, at the right time and place.
8.1.1.1. This "pre-communication" also occurs via radio between EMS and hospital facilities.
8.1.1.1.1. Allows for flow adjustments if a patient may not receive timely care due to current ED capacity, including other emergencies.
8.1.2. Women's Care and Children's Care specialty designations.
8.2. Further clarifications specifically around the transferring of patients are being repeatedly outlined at a national, state and local level.
8.2.1. Nationally through expanded clarification of guidelines.
8.2.1.1. "Section 42 CFR 489.20(l) of the provider’s agreement requires that hospitals comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. Under the provisions of §489.24, hospitals with an emergency department that participate in Medicare are required under EMTALA to do the following (including but not limited to): • Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC (or the capability or capacity to admit the individual)"
8.2.2. Locally by defined EMS protocols.