Groups Seek Parity for Emergency Psych Patients

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.