WALLEY v. YORK HOSPITAL
Filing
9
DECISION AND ORDER ON MOTION TO DISMISS granting 5 Motion to Dismiss for Failure to State a Claim By JUDGE D. BROCK HORNBY. (jib)
UNITED STATES DISTRICT COURT
DISTRICT OF MAINE
GELI WALLEY,
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PLAINTIFF
V.
YORK HOSPITAL,
DEFENDANT
CIVIL NO. 2:18-CV-126-DBH
DECISION AND ORDER ON MOTION TO DISMISS
The issue presented by this 12(b)(6) motion is whether the plaintiff’s onecount Complaint has stated a claim under the Federal Emergency Medical
Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd et seq., as
opposed to an ordinary medical malpractice claim under Maine state law. I
conclude that she has failed to state a federal claim and GRANT the defendant’s
motion to dismiss.
FACTS
I take the facts as stated in the plaintiff’s complaint, as well as any
concessions the parties have made.
The defendant York Hospital is a
participating hospital with a dedicated emergency department within the
meaning of EMTALA. Compl. ¶¶ 4, 9 (ECF No. 1). For purposes of its motion,
York Hospital admits that it is covered by EMTALA and that it operates an
emergency department. Def.’s Mot. 4 n.3 (ECF No. 5).
The plaintiff came to the Hospital’s Emergency Department around 8:00
p.m. on March 23, 2016, believing that she was having a stroke. Compl. ¶¶ 1819. (York Hospital admits that the plaintiff came to the hospital on March 23,
2016, seeking treatment. Def.’s Mot. 4 n.3.) She was formally admitted to the
hospital at 11:03 p.m. with a stroke diagnosis, namely, “trans cerebral ischemic
attack uns.” Compl. ¶¶ 34-36. On the evening of March 25, 2016, York Hospital
transferred her to Maine Medical Center. Compl. ¶¶ 52, 54; Pl.’s Opp’n 5 (ECF
No. 6). The plaintiff had another stroke before she was transferred. Compl. ¶ 53.
ANALYSIS
This court, the First Circuit, and the Department of Health and Human
Services’ Centers for Medicare and Medicaid Services (CMS) have repeated time
and again that EMTALA is not a medical malpractice statute. See, e.g., RamosCruz v. Centro Medico del Turabo, 642 F.3d 17, 18 (1st Cir. 2011) (it “is a limited
anti-dumping statute, not a federal malpractice statute.”); Correa v. Hosp. San
Francisco, 69 F.3d 1184, 1193 (1st Cir. 1995); Feighery v. York Hosp., 59 F.
Supp. 2d 96, 102 (D. Me. 1999); Medicare Program; Clarifying Policies Related
to
the
Responsibilities
of
Medicare-Participating
Hospitals
in
Treating
Individuals With Emergency Medical Conditions, 68 Fed. Reg. 53222, 53223
(Sept. 9, 2003) (“In enacting [the private right of enforcement in EMTALA],
Congress did not intend for the statute to be used as a Federal malpractice
statute.”).
Instead, Congress enacted EMTALA to stop so-called hospital
“dumping” practices by which some hospitals denied admission to patients who
lacked insurance or ability to pay. Congress did not create the federal law to
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supersede state law on medical malpractice.1
Fraticelli-Torres v. Hosp.
Hermanos, 300 F. App’x 1, 3-4 (1st Cir. 2008); Bryan v. Rectors & Visitors of
Univ. of Virginia, 95 F.3d 349, 351-52 (4th Cir. 1996); Feighery, 59 F. Supp. 2d
at 102 (collecting cases). I assess the Complaint in that framework.
This one-count Complaint asserts that York Hospital’s treatment of the
plaintiff violated EMTALA as follows: (1) The Hospital failed to provide an
appropriate medical screening examination of her stroke symptoms in a timely
manner; (2) it failed to stabilize her emergency medical condition in a timely
manner; (3) it failed to admit her within a reasonable amount of time; and (4) it
failed to transfer her in a timely manner to a primary stroke center. Compl.
¶¶ 57-60. York Hospital’s motion seeks to dismiss the entire Complaint and
argues that EMTALA permits a cause of action founded upon only (1) failure to
provide an appropriate screening and (2) transferring her without first stabilizing
her condition, i.e., the first two assertions.
Def.’s Mot. 3-4. The plaintiff’s
response implicitly accepts this characterization of her Complaint, argues that
her first two assertions are sufficient to state a claim, and does not address the
last two. Pl.’s Opp’n 2. The first two, therefore, are the claims that I assess.2
Because the plaintiff has not argued that her federal cause of action survives
even if I rule in the Hospital’s favor on the first two claims, I conclude that she
is not pursuing the other two as separate federal claims.
In any event, the
1 The statute specifies that it does “not preempt any State or local law requirement, except to the
extent that the requirement directly conflicts with a requirement of this section.” 42 U.S.C.
§ 1395dd(f).
2 I need not decide whether York Hospital correctly characterizes EMTALA as limited to these two
obligations on the part of hospitals. These are the only two that are relevant as the case is
pleaded.
3
plaintiff has not shown that they are independent EMTALA violations as opposed
to ordinary medical malpractice claims.3
I choose to address in reverse order the two claims in dispute.
Failure to Stabilize
EMTALA provides that when a hospital determines that an individual has
an emergency medical condition, it “must provide . . . such treatment as may be
required to stabilize the medical condition” or “transfer [her] to another medical
facility.” 42 U.S.C. § 1395dd(b)(1). There are special conditions for transferring
a patient who has not been stabilized, so as to avoid the “dumping” that EMTALA
sought to end. Id. § 1395dd(c). CMS has promulgated the following regulation
regarding the stabilization requirement:
If a hospital has screened an individual . . . and found the
individual to have an emergency medical condition, and
admits that individual as an inpatient in good faith in order
to stabilize the emergency medical condition, the hospital
has satisfied its special responsibilities under this section
[concerning the obligation to stabilize] with respect to that
individual.
42 C.F.R. § 489.24(d)(2)(i). The regulation also states: “If the hospital admits the
individual as an inpatient for further treatment, the hospital’s obligation under
this section ends, as specified in paragraph (d)(2) of this section.” Id.
3 I discuss the delayed admission claim infra at note 11. As for the late transfer assertion, the
First Circuit has said: “A hospital’s negligent medical decision not to transfer a critical patient
promptly to another hospital to receive necessary treatment might trigger state-law medical
malpractice liability, but it could not constitute an EMTALA anti-dumping violation.” FraticelliTorres, 300 F. App’x at 7. Even if the complaint is read loosely to allege not a late transfer but
an “inappropriate” transfer in violation of 42 U.S.C. § 1395dd(c), that claim would be foreclosed
in this case by the CMS regulations, discussed in text, that terminate EMTALA obligations—
including compliance with § 1395dd(c)—once an individual has been admitted as an inpatient in
good faith. 68 Fed. Reg. at 53245 (“[T]ransfer and stability issues for [an] individual, once he or
she is admitted [as an inpatient], would [not] be governed by . . . EMTALA requirements.”).
4
§ 489.24(a)(1)(ii) (emphasis added). The plaintiff acknowledges in her Complaint
that York Hospital did admit her as an inpatient on March 23, 2016; the
Complaint does not allege that the Hospital was not acting in good faith in doing
so.4 Under this regulation, then, York Hospital had no EMTALA stabilization
obligation, although it may have had state law medical malpractice obligations.
York Hospital explicitly relied upon this regulation in both its Motion and its
Reply. The plaintiff in her opposition simply did not address the regulation.5
CMS has given this regulatory interpretation of the EMTALA stabilization
requirement considerable attention. First, in 2002, recognizing a difference of
opinion among courts, CMS proposed applying the stabilization requirement to
inpatients who were admitted in order to stabilize their emergency medical
conditions. Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 2003 Rates, 67 Fed. Reg. 31404, 31475
(May 9, 2002).6 After extensive negative public comments, and consideration of
In her legal memorandum, the plaintiff argues that bad faith is unnecessary, Pl.’s Opp. 10, but
the regulation speaks of admitting “an inpatient in good faith.” 42 C.F.R. § 489.24(d)(2)(i). She
also argues that a jury could find that her hospital admission was a subterfuge, and could infer
bad faith. Pl.’s Opp. 10. And her Complaint states in its final paragraph that “YORK HOSPITAL’s
conduct in violation of EMTALA was so outrageous that malice may be implied.” Compl. ¶ 62.
That assertion seems to be directed to her claim for punitive damages. In any event, I conclude
that she must actually allege subterfuge or the absence of good faith on the Hospital’s part under
the strictures of Fed. R. Civ. P. 11 in order to avoid the regulation’s treatment of inpatients.
5 In her argument about stabilization, the plaintiff relies upon Lopez-Soto v. Hawayek, 175 F.3d
170, 174-75, 177 n.4 (1st Cir. 1999). But that case predated the CMS regulation. First Circuit
stabilization cases decided after the regulation was adopted have not needed to address the
duration of the stabilization requirement. See, e.g., Alvarez-Torres v. Ryder Mem. Hosp., Inc.,
582 F.3d 47, 51-52 (1st Cir. 2009) (holding that there was no federal stabilization obligation for
a patient who was admitted but not transferred). In Fraticelli-Torres, 300 F. App’x at 3-4, the
court noted that the plaintiff there contended that the duty of stabilization continued even after
admission (citing Lopez-Soto) and that the defendants did not dispute the contention, but the
court was not called upon to decide the issue or address the CMS regulation.
6 CMS was prompted to do so after the issue came up in the context of Roberts v. Galen of
Virginia, Inc., 525 U.S. 250 (1999). The Solicitor General advised the Court during the course of
Galen that CMS “would develop a regulation clarifying its position on th[e] issue.” 67 Fed. Reg.
4
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the federal case law, however, CMS in 2003 adopted the version now in effect,
68 Fed. Reg. 53222, that the stabilization obligation is satisfied and ends upon
patient admission so far as a federal remedy is concerned.
§ 489.24(a)(1)(ii), (d)(2)(i).
42 C.F.R.
CMS reexamined the issue in 2012 and after
considering additional public comment decided to leave the regulation as it
stands.
Medicare Program; Emergency Medical Treatment and Labor Act
(EMTALA): Applicability to Hospital Inpatients and Hospitals With Specialized
Capabilities, 77 Fed. Reg. 5213 (Feb. 2, 2012).7
I have not found any First Circuit case that addresses the inpatient
regulation. The “vast majority” of cases outside the First Circuit have followed
it. Thornhill v. Jackson Par. Hosp., 184 F. Supp. 3d 392, 399 (W.D. La. 2016)
(collecting cases). In Moses v. Providence Hosp. and Med. Ctrs., Inc., 561 F.3d
573, 583 (6th Cir. 2009), the Sixth Circuit refused to apply it, finding it contrary
to the plain language of the statute, but the Sixth Circuit’s refusal is arguably
dictum because the regulation was not promulgated until after that plaintiff’s
hospital stay. Id. at 583-84. In any event, the plaintiff here has not challenged
the validity of the regulation and, in the absence of argument, I do not engage in
the conventional Chevron8 analysis of whether the statute is ambiguous and
whether this is a permissible interpretation.9 I simply apply the regulation, as
at 31475. Galen did not decide the issue, holding only that, to recover under § 1395dd(b), a
plaintiff need not prove that a hospital acted with an improper motive in failing to stabilize her.
7 The Solicitor General apparently advised the Court in 2010 that CMS “had committed to
initiating a rulemaking process to reconsider” the inpatient exception; the rulemaking began in
December of that year. 77 Fed. Reg. at 5216.
8 Chevron, U.S.A., Inc. v. Nat. Res. Def. Council, Inc., 467 U.S. 837 (1984).
9 I do note that at this point, the Sixth Circuit’s conclusion is an outlier.
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the “vast majority” of cases have done. On the facts she alleges in her Complaint,
the plaintiff has no federal cause of action for failure to stabilize.
Appropriate Medical Screening
EMTALA also provides that a hospital emergency department “must
provide for an appropriate medical screening examination . . . to determine
whether or not an emergency medical condition . . . exists.”
42 U.S.C.
§ 1395dd(a).
On the issue of appropriate medical screening, the First Circuit has said:
A hospital fulfills its statutory duty to screen patients in its
emergency room if it provides for a screening examination
reasonably calculated to identify critical medical conditions
that may be afflicting symptomatic patients and provides
that level of screening uniformly to all those who present
substantially similar complaints.
The essence of this
requirement is that there be some screening procedure, and
that it be administered even-handedly.
Correa, 69 F.3d at 1192 (1st Cir. 1995) (emphasis added) (citations omitted). The
Circuit immediately added:
EMTALA does not create a cause of action for medical
malpractice. Therefore, a refusal to follow regular screening
procedures in a particular instance contravenes the statute,
but faulty screening, in a particular case, as opposed to
disparate screening or refusing to screen at all, does not
contravene the statute.
Id. at 1192-93 (emphasis added) (citations omitted). The plaintiff here has not
asserted that York Hospital refused to follow regular screening procedures or
that it had no screening procedures.
She also has not asserted that York
Hospital engaged in disparate screening or that it refused to screen her at all.10
In her legal memorandum, the plaintiff cites Repp v. Anadark Mun. Hosp., 43 F.3d 519, 522
(10th Cir. 1994), for the point that a hospital’s failure to follow its own standard screening
procedure violates the federal screening requirement. Pl.’s Opp’n 8. I observe that in Cruz10
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Instead, the plaintiff acknowledges that York Hospital did recognize her
emergency medical condition and “did in fact initiate an appropriate screening
examination.” Pl.’s Opp’n 2 (citing Compl. ¶¶ 20, 23). Her Complaint says that
when she arrived, “York Hospital immediately initiated an acute stroke protocol.”
Compl. ¶ 20. But she argues that ultimately her screening was not “full and
appropriate,” Compl. ¶ 40, and that whether she “ultimately received an
‘appropriate screening examination’ within the meaning of EMTALA is a factual
question that can only be answered by a medical expert.” Pl.’s Opp’n 2-3.
I agree that the quality of the screening examination the plaintiff received
may indeed be a factual and expert question, but it raises Maine medical
malpractice law issues, not a federal EMTALA claim for refusing to screen or
disparate screening.
Under this District’s and this Circuit’s caselaw, the
plaintiff’s Complaint does not state a federal claim for failing to provide
appropriate medical screening.11
Vazquez v. Mennonite Gen. Hosp., Inc., 717 F.3d 63 (1st Cir. 2013), the First Circuit said that
“[w]hen a hospital prescribes internal procedures for a screening examination, those internal
procedures set the parameters for an appropriate screening.” Id. at 69 (cleaned up). But the
Complaint nowhere alleges that York Hospital failed to satisfy that standard of following its own
procedures.
The legal memorandum also says that the screening examination “was
unreasonably delayed in violation of hospital protocol,” Pl’s Opp’n 8, but the Complaint does not
include that allegation about York Hospital protocol.
11 The plaintiff does state in her legal memorandum that “a hospital’s delay in screening a patient
is actionable under § 489.24(d)(4).” Pl.’s Opp’n 8 (ECF No. 6). What that regulation states is
that:
A participating hospital may not delay providing an appropriate medical screening
examination . . . in order to inquire about the individual’s method of payment or
insurance status.
42 C.F.R. § 489.24(d)(4)(i) (emphasis added). The regulation follows 42 U.S.C. § 1395dd(h),
which has similar language. But the Complaint does not allege that York Hospital delayed her
screening examination for such a purpose. See also Matta-Rodriguez v. Ashford Presbyterian
Comm. Hosp., 60 F. Supp. 3d 300, 310 (D.P.R. 2014) (charge of “untimely” screening is not
sufficient; must charge refusal to screen or a screening inconsistent with regular screening
procedures).
8
CONCLUSION
I express no view on whether the plaintiff’s stroke treatment at York
Hospital amounts to medical malpractice under Maine law. What I conclude is
that her allegations do not state a federal claim under EMTALA, a federal statute
designed to end some hospitals’ practice of turning away patients who needed
care. “Congress did not intend EMTALA to supplant existing state-law medical
malpractice liability with a federal malpractice standard of care; the minimal
screening and stabilization requirements were designed solely to prevent the
specific injury of patient ‘dumping,’ which state malpractice law often could not
redress.” Fraticelli-Torres, 300 F. App’x at 4 (citation omitted).
The defendant’s motion to dismiss is GRANTED.
SO ORDERED.
DATED THIS 27TH DAY OF JULY, 2018
/S/D. BROCK HORNBY
D. BROCK HORNBY
UNITED STATES DISTRICT JUDGE
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