1. 3 I's
1.1. Impact
1.1.1. Maes v. Charter Commc'n, 345 F. Supp. 3d 1064 (W.D. Wis. 2018)
1.1.1.1. Although this case involved telemarking, Beller was cited for whether rules would apply retroactively
1.1.2. Guardian v. Health & Hosp. Corp. of Marion Cty., No. 115CV00964LJMTAB, 2016 WL 6822468 (S.D. Ind. Nov. 18, 2016)
1.1.2.1. Case cites Beller as precedent for EMTALA violation referencing patient dumping, failure to properly screen patient, failure to stabilize patient and discharged on both occasions
1.1.3. Gillispie v. RegionalCare Hosp. Partners, Inc., No. CV 13-1534, 2014 WL 12599597 (W.D. Pa. May 19, 2014),
1.1.3.1. Case cites Beller as precedent for EMTALA violation of patient dumping and unlawful retaliatory discharge for her complaint on CEO Cynthia Cowie who wouldn't let her file the EMTALA violation
1.2. Importance
1.2.1. This case was important for administrative law because the court made clear that "great weight" must be given to the intent of the agency the issued the rule in question.
1.2.1.1. It is a signal to the agencies that they must make their intent as clear as possible in their documents.
1.2.1.2. It is also a signal to plaintiffs and defendants that these types of cues matter and should be carefully considered when making arguments before the court.
1.2.1.2.1. For hospitals in particular, it means they need to pay close attention to agency rules, a tremendous burden since DHHS puts out hundreds of pages of rules per year that apply to Medicare-participating hospitals.
1.2.2. The case is also important to hospital administrators when deciding whether or not the hospital should purchase an ambulance.
1.2.2.1. Ambulances are very expensive, and often out of reach for community volunteer ambulance corps to purchase on their own. Based on this ruling, the hospital can feel comfortable purchasing an ambulance and allowing it to operate under the communitywide EMS protocols without having to worry about extra liability under EMTALA.
1.2.3. Ruling sets precedent that violations of EMTALA are not applicable to ambulances operating under EMS protocols in terms of "coming to emergency room"
1.2.4. Clarifies that even though laws can only be retroactively applied to cases with congressional approval if a change is deemed to clarify and alleviate confusion it is not a substantive change and can be used used
1.3. Influence
1.3.1. Rulings like this one increase the administrative burden on hospitals by adding an extra layer of complexity to interpreting and applying agency regulations.
1.3.1.1. This adds to the long list of reasons why every hospital needs to have a lawyer on staff or on retainer, an expensive but necessary requirement in our modern compliance environment.
1.3.2. Protects ambulance services from being held liable for taking patients to closer hospitals when directed
2. IRAC Analysis
2.1. Facts
2.1.1. Parties
2.1.1.1. Appellant: Joshua Beller (Minor) & Melissa Welch (Mother)
2.1.1.2. Appellee: Health and Hospital Corporation of Marion County, Indiana d/b/a Wishard Memorial Hospital
2.1.2. What Happened
2.1.2.1. June 14, 2001, Melissa Welch, who was 34 weeks pregnant called 911 and a Wishard-owned ambulance was dispatched
2.1.2.2. Upon arrival paramedics determined her water had broken and she had a prolapsed umbilical cord
2.1.2.3. After attempting to relieve the pressure, paramedics consulted with a nurse at Welch's OB's office and all agreed Welch needed to be transferred to the nearest hospital
2.1.2.4. Paramedics coordinated with St. Francis Beech Grove ER, the nearest hospital, and transported her there
2.1.2.5. Beech Grove did not have an OB facility so the physician examined her and had her sent to St. Francis Hospital South to deliver her baby
2.1.2.6. Joshua Beller was delivered at Hospital South by C-Section but had suffered brain damage as a result of Hypoxia
2.1.3. Procedural History
2.1.3.1. Appellant filed suit against Appellee for violating EMTALA for "failing to stabilize Melissa Welch and her minor son, Joshua, during an emergency medical situation"
2.1.3.1.1. District Court granted Summary Judgement for the defendant, Wishard, and Plaintiffs appealed
2.2. Issue Before the Court
2.2.1. Whether the Plaintiffs had "come to the emergency room" of Wishard Memorial Hospital when they were transported in the Wishard ambulance
2.2.2. Whether the DHHS's 2003 amended definition of "come to the emergency room" under EMTALA can be retroactively applied - this depends on if the 2003 change was a clarification or a substantive change.
2.3. Rule of Law
2.3.1. Emergency Medical Treatment and Labor Act (EMTALA)
2.3.1.1. Enacted to address patient "dumping" in which hospitals would not provide equal level of care to both insured and uninsured patients or by transferring them to other emergency facilities
2.3.1.2. 2001 regulation defines "come to the emergency room" as the individual being on hospital property
2.3.1.2.1. Includes ambulances owned and operated by the hospital even if the ambulance is not on hospital grounds
2.3.1.3. 2003 Amendment addresses when a person is deemed not to have come to the emergency room
2.3.1.3.1. This applies when the ambulance is operating under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance.
2.4. Application
2.4.1. Plaintiff (Walsh)
2.4.1.1. Under the 2001 definition, Walsh had "come to the emergency room" of Wishard Hospital because she was transported in a Wishard-owned ambulance. This definition should apply.
2.4.1.1.1. It is not clear that the DHHS intended for the 2003 change to be a clarification.
2.4.1.1.2. The District Court gave "undue deference" to DHHS's characterization of the change as a clarification and should have conducted its own analysis.
2.4.2. Defendant (Hospital Corp.)
2.4.2.1. Under the 2003 definition, Walsh had not "come to the emergency room" because the Wishard-owned ambulance was operating under the communitywide EMS protocols. This definition should apply.
2.4.2.1.1. DHHS plainly started in the final rule implementing the changed definition that the change was a clarification intended to alleviate confusion about the status of hospital-owned ambulances operating under communitywide EMS protocols.
2.4.3. Court
2.4.3.1. When determining whether a rule is a clarification or substantive change, the court should give great weight to the intent of the promulgating agency.
2.4.3.1.1. In the final rule, DHHS repeatedly and unambiguously stated that the change was a clarification to "address confusion as to the scope of the 2001 definition." The court goes on to cite four example phrases.
2.4.3.2. The specific clarification was to the meaning of when an ambulance is "operated by" a hospital, a key component to the two part definition "owned and operated by the hospital."
2.4.3.2.1. The Plaintiff only focused on "owned...by the hospital," while ignoring the second half of the definition, "and operated by the hospital."
2.4.3.3. EMS protocols were created after 2001, creating confusion because an ambulance could now be owned by a hospital but not operated by it.
2.4.3.3.1. The 2003 rule is not inconsistent with the 2001 rule because it does not change the "owned and operated" definition - it simply provides clarity to the meaning of operated.
2.5. Conclusion
2.5.1. The decision of the District Court granting summary judgment in favor of the defendant was Affirmed