Appendix ‘A’

PATIENT DUMPING-

WHAT IS THE LEGAL

REMEDY?

Submitted by :-

Shubham Jain

Division A Roll No 16 Class BBA.LLB of

Symbiosis Law School, NOIDA

Symbiosis International University, PUNE

In

June, 2011

Under the guidance of

Dr. C. J. Rawandale

Director

Symbiosis Law School, Noida

Appendix ‘B’

C E R T I F I C A T E

The project entitled “Patient Dumping-What is the legal remedy?” submitted

to the Symbiosis Law School, NOIDA for Law of Torts, MV Accident and Consumer

Protection Laws II as part of Internal assessment is based on my original work

carried out under the guidance of Dr. C. J. Rawandale from 25 April,2011 to 22

June,2011. The research work has not been submitted elsewhere for award of any

degree.

The material borrowed from other sources and incorporated in the thesis has been duly acknowledged.

I understand that I myself could be held responsible and accountable for plagiarism, if any, detected later on.

Signature of the candidate

Date:

ACKNOWLEDGEMENT

It is a great pleasure for me to put on records my appreciation

and gratitude towards Dr. C. J. Rawandale, Director for his

immense support and encouragement all through the preparation

of this report. I would again like to thank my faculty

Dr.C.J.RAWANDALE (Project Guide) for his valuable support and

suggestions for the improvement and editing of this project

report. Last but not the least, I would like to thank all the friends

and others who directly or indirectly helped me in completing my

project report.

Date- June 24,2011 Shubham Jain

Roll no- 16

Appendix ‘C’

Page 1 - Appendix ‘A’

Page 2 - Certificate (Appendix ‘B’)

Page 3 - Acknowledgement

Page 4 - Index (Appendix ‘C’)

Page 5-6 - Patient Dumping-An Introduction

Page 6-7 - Need For Legal Remedy

Page 6-9 - Legal remedy

Page 10 - Cases INvolving

Page 11 - Recommendations

Page 11-12 - Conclusions

Page 13 - Appendix ‘D’

Patient Dumping

Patient Dumping   : An Introduction

Although the main difficulty for patients in "right to refuse medical

treatment" cases is ending the medical care that they receive, there are

situations in which patients have difficulty gaining admittance to hospitals

to obtain medical care. Such examples of patient denial include: a man with

severe burns over ninety-five percent of his body who was refused

admittance at over forty hospitals with burn centers despite pleas for

admittance from the man’s personal physician; a man with a knife wedged

into his spine, and a woman entering labour with what was described as the

"highest blood pressure" that the doctor who refused to provide the woman

with care "had ever seen." The common thread in these "patient dumping"

situations is that none of these potential patients had medical insurance or

were otherwise patients who were unattractive to hospitals. Often known

as "demarketing of services" or as "management of patient mix," patient

dumping is the hospital practice of transferring or refusing to treat

individuals who are indigent or uninsured, or otherwise undesirable as

patients. Patient dumping has origins in the common law’s "no duty" rule,

which provides that hospitals are not required to treat all patients that seek

care, and in some cases, need not even specify a reason for rejecting the

patient.8 Hospitals often "dump" patients who arrive at hospital wards

without any health insurance, or because indigent patients’ only source of

insurance is Medicaid -- a program known among doctors to provide low

reimbursement payments to physicians, themselves. The frequency of

patient dumping in cases failing under the no duty rule was increased by

economic pressures placed upon hospitals over the

past decade.

“The premature discharge of Medicare or indigent patients from hospitals

for economic reasons”

Patient dumping represents a cold, unconscionable disregard for human

life. The act of patient dumping occurs when patients presenting in the

emergency department are denied emergency medical care or stabilizing

treatment based on economic or non-economic grounds, such as the

patient’s race, ethnicity, sexual orientation, or contraction of a socially

unacceptable disease.

Some of the Economic incentives for patient dumping typically revolve

around four aspects of healthcare and its administration:-

the increasing number of uninsured;

healthcare cost containment measures;

the common law no-duty rule;

and ineffective state statutory responses.

The general premise for the intentional tort of patient dumping is that one

who intentionally causes injury to another is subject to liability to the other

for that injury, if his conduct is without justification under the

circumstances. Increases in the number of uninsured individuals have

caused a significant strain on the ability of hospitals and physicians to

provide care to the indigent while remaining solvent. With an increase in

the number of uninsured individuals, there has been a documented

increase in the number of patients being dumped. The common law no-

duty rule also serves as a foundation for Patient dumping. Under the

common law, neither hospitals nor physicians have an affirmative duty to

treat patients; therefore, either hospital or physician, or both, may

acquiesce to economic pressure and refuse to treat individuals with

emergency medical conditions

Need for Legal Remedy

Patient Dumping is intentional, not based on negligence, and unrelated to

medical issues involving patient care. It exists in a zone outside the

practice of medicine and within the realm of discrimination. Accordingly, in

an attempt to right this civil wrong. There was a proposal for the courts to

recognize a new intentional tort of patient dumping as a state cause of

action. The recognition of such a tort be limited to circumstances where a

patient’s transfer is based solely on economic or non-economic, non-

medical discriminatory reasons resulting in patient harm and not where the

transfer is a part of a medical decision regarding patient care. Although one

intermediate state appellate court has recently attempted to sustain such a

cause of action, on review it was overturned with arguably sophistic

reasoning. Because there may be a reluctance to recognize a new

intentional tort as part of our already burdened legal system. This

addresses the need for and elements of a new cause of Action of Legal

Remedy for patient dumping.

Health care providers are not entirely to be blame for Patient Dumping.

Hospitals used to be able to support indigent care through “cost-shifting,”

charging more from those who could afford to pay to provide care to those

who could not. That scheme changed in the last decade as the number of

for-profit hospitals increased and the government and private industry

began in earnest to pursue containment of health care costs. Competitive

pressures slowly rendered the subsidy system less and less tenable. Even

voluntary, not-for-profit hospitals have felt the pressure to reduce costs.

Congress was concerned that hospitals were abandoning emergency care

patients as a cost-cutting measure, and knew that patient dumping

decreased the quality of care received by the dumped indigent or

uninsured patients. This decreased care ultimately led to higher morbidity

and mortality levels so Congress created EMTALA to provide adequate

emergency medical services to the indigent and uninsured who seek

emergency care.

The quandary of patient dumping is rooted in the facts that there are

millions of people in this world who are in need of health care with no

means of paying for it. The critical question becomes: “Who will pay?”

Someone must, and the choices are limited. Either the government,

through tax dollars, must foot the bill, or health care providers must

assume the burden themselves. One can condemn the insensitivity of the

statement that began this section, but cannot ignore the unfairness to

health care providers of attempting, in effect, to imposing national health

insurance. COBRA and other efforts are required for hospitals to treat

indigents will help, but effective treatment of patient dumping cannot occur

until a method is devised for adequately compensating those who provide

health care to indigents. Thus it was realized that there was a great need to

control the incidence of patient dumping.

Legal Remedy

Any proposed solution for patient dumping requires an understanding of

the basis for its existence. This understanding comes from considering the

incentives for, epidemiology of, congressional concerns about, and

persistence of patient dumping.

In 1856 Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

came into law. COBRA contained a Medicare and Medicaid amendment now

commonly known as EMTALA. It was enacted during an era of escalation in

the number of uninsured patients that paralleled increasing reports of

“patient dumping. “Some emergency physicians and hospitals had

reportedly denied emergency medical care to indigent and uninsured

patients or transferred them to a public or charity hospital without first

stabilizing their emergency medical condition. Frequently, the transferred

patients had medical or surgical conditions which rendered them unstable

or critically ill, or were pregnant and in labor. EMTALA requires that

hospitals conduct a “medical screening examination” and provide

“necessary stabilizing treatment” to any patient seeking emergency

medical care in a hospital emergency department. The examination’s

purpose is to determine whether the person suffers from an “emergency

medical condition.” If an individual suffers from such a condition, either

necessary emergency stabilizing care must be provided or the patient must

be transferred in accordance with EMTALA provisions. It is defined in the

EMTALA that when an individual at a hospital has an unstabilized

emergency medical condition, as defined by the statute, the hospital may

not transfer the individual unless a physician has signed a legal

certification. The legal certification indicates that “based upon the

information available at the time of transfer, the medical benefits

reasonably expected from the provision of appropriate medical treatment

at another medical facility outweigh the increased risks to the individual

and, in the case of labor, to the unborn child. This legal certification process

implies that the transferring emergency physician believes that the

receiving facility has the necessary resources, capabilities, and expertise to

stabilize the patient’s emergency medical condition. The legal certification

must weigh not merely mention, the medical risks and benefits associated

with the transfer of the unstable patient.

Civil monetary penalties

EMTALA empowers the DHHS, upon the authorization of the Attorney

General of the United States, to initiate administrative proceedings

for civil penalties against hospitals and physicians that negligently

violate EMTALA. EMTALA specifically states that “[a] participating

hospital that negligently violates a requirement of [EMTALA] is

subject to a civil money penalty of not more than $50,000 for each

such violation. The aggrieved hospital or physician has a right of

appeal to the Court of Appeals.

Additionally, EMTALA provides that physicians who examine or

transfer a patient and who “negligently” violate a requirement of

EMTALA are also subject to civil monetary penalties.

Civil enforcement

Under EMTALA civil enforcement, if a patient suffers harm because a

hospital violated EMTALA requirements, that patient can sue the

hospital for damages under the personal injury law of that state or

seek equitable relief. There is no corresponding EMTALA civil

enforcement provision under which an individual who suffers personal

harm may directly proceed in a civil action against an emergency

physician.

When a medical facility suffers financial loss, relief is also available.

Under either circumstance, whether a suit by a person harmed or by

a medical facility, no action may be brought more than two years

after the date of the violation.

Cases involving

Bryan v/s. Rectors & Visitors of the University of Virginia Medical

Center.

In this case the the court identified a hospital’s obligation under

EMTALA as pertaining to “immediate, emergency stabilizing

treatment,” rather than having to provide treatment indefinitely.

Thus, the court narrowly interpreted the scope of the temporal

duration of the EMTALA obligation by declaring that “the stabilization

requirement was intended to regulate the hospitals care of the

patient only in the immediate aftermath of the act of admitting a

patient for emergency treatment.”

Hussain v. Kaiser Foundation Health Plan of the Mid-Atlantic State.

Eastern District of Virginia, relying on explained that the statutory

language clearly refers back to the emergency medical condition

“observed upon the patient’s initial appearance at the hospital’s

emergency department. “Accordingly, the court noted that “neither

in its text nor its avowed purpose does EMTALA reach into the

hospital room of a patient admitted for several hours to redress the

failure of hospitals to follow standard medical procedures in

connection with in-patient hospital treatment.

Lopez-Soto v. Hawayek.

The court held that EMTALA “unambiguously imposes “certain duties

in the emergency care of an individual “regardless of how that person

enters the institution or where within the walls he may be when the

hospital identifies the problem.”

Further, the court explained that nothing in the provisions of EMTALA

suggests a “necessary relationship” between a hospital’s obligations

and the identity of the department within the hospital to which the

afflicted individual presents himself.

Recommandations

Over the past sixteen years, numerous suggestions have been made to

resurrect the sloppy EMTALA legislation to curb the rise of patient dumping.

Some have suggested even more federal legislation. Others have

suggested segmental statutory resurrection by either including new

phrases, providing definitions for clarity, including the language of tort, or

even by having Congress attempt to repair curatively the mis-match

between its original congressional intent and the final statutory language.

Some have suggested criminal action against hospitals, physicians, and

nurses. Although complex, our solution is the creation of a new state cause

of action: the intentional tort of patient dumping.

The intentional tort of patient dumping is based in public policy, although

influenced by antecedents in the law of contract, medical malpractice tort,

the constitutional right to be free from discrimination, and the federal

statutory right to emergency medical care. Clearly, however, although

influenced by other bodies of law, the true nature of patient dumping has

not been duly recognized by contract, tort, constitutional or federal law.

Thus, without duly recognizing the nature of the act and harm of patient

dumping, current law does not fit the circumstances of patient dumping

and therefore is unable to provide proper redress. And, notwithstanding

influences from other branches of law, because the nature and harm of

patient dumping remains unredressed, it continues to grow and cause harm

to thousands of unsuspecting individuals at their moments of greatest need

and reliance upon those expert in emergency care.

Conclusion

Lastly, we define the nature and act of patient dumping as completely

distinct from a patient’s medical care or medical transfer decision. That is,

it is an intentional act of depriving a person of emergency medical care not

based upon any medical reason, but rather based on discrimination; either

economic or noneconomic non-medical grounds. Accordingly, we anticipate

that its use will be strictly reserved for application to patient transfers that

are the result of shameful acts of discrimination. Patient dumping is a

dangerous but predictable accompaniment to the market-driven health

care system in the richest nation in the world. As there is little incentive for

compliance with EMTALA, some healthcare professionals and facilities have

disregarded their obligations and engaged in patient dumping, on the basis

of purely economic or non-economic, non-medical discriminatory grounds,

without apparent fear of punishment. Indeed, no measure in law currently

exists to provide punitive measures for patient dumping. As state

regulatory and federal legislation have been unsuccessful in their attempt

to thwart patient dumping, and because the federal government simply

cannot regulate patient transfers in distant emergency departments, we

believe it is time for state courts to recognize the intentional tort of patient

dumping and place civil actions in the hands of the victims, rather than in

the hands of a federal prosecutor. Because such a cause of action

recognizes that patient dumping is intentional, not negligence based, and

occurs in a zone outside the practice of medicine and professional medical

care decision making, it should sound in intentional tort. Accordingly, an

intentional tort of patient dumping would have a strong and beneficial

effect on the attention and care provided those who present to emergency

departments with emergency medical conditions. Finally, justice requires

that the on-going harm caused by patient dumping be properly redressed.

Appendix ‘D’

I. Books Referred

1. THOMAS A. GIONIS,CARLOS A. CAMARGO, and ANTHONY S. ZIT,The intentional tort of patient dumping: a new state cause of action to address the shortcomings of the federal emergency medical treatment and active labour act (EMTALA)

II. Websites referred

1. www.ssrn.com 2. www.emraldinsight.com