Court Opinion

ID: 9671813
Source: CourtListenerOpinion
Date Created: 2023-08-24 03:43:35.50871+00
Date Added: 2024-06-11T18:16:12.181652
License: Public Domain

PATIENCE DRAKE ROGGENSACK, J.
¶ 47. (dissenting). The majority errs in its review of the Emergency Medical Treatment and Active Labor Act (EMTALA) screening claim by concluding that Preston's complaint1 states a claim upon which relief can be granted, as did the court of appeals, because its analysis of EMTALA overlooks Bridon's status as an inpatient.2 I conclude that the screening provision of EMTALA, 42 U.S.C. § 1395dd(a) (1994),3 does not apply to hospital inpatients. Because Bridón became an inpatient when his mother was admitted before his birth, the screening provision of EMTALA does not apply to him. Therefore, because I would affirm the court of appeals decision dismissing Preston's claim, albeit on different grounds, I respectfully dissent.
*292I. DISCUSSION
A. Standard of Review
¶ 48. We review a circuit court's decision granting summary judgment independently, but we apply the same methodology as the circuit court. Mrozek v. Intra Fin. Corp., 2005 WI 73, ¶ 14, 281 Wis.2d 448, 699 N.W.2d 54 (citing Smaxwell v. Bayard, 2004 WI 101, ¶ 12, 274 Wis. 2d 278, 682 N.W.2d 923). Pursuant to Wis. Stat. § 802.08(2), summary judgment "shall be rendered if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law."
¶ 49. As our first step in a summary judgment analysis, we determine whether Preston's complaint states an EMTALA claim for which relief can be granted. See Brownelli v. McCaughtry, 182 Wis. 2d 367, 372, 514 N.W.2d 48 (Ct. App. 1994). We then examine the answer to determine whether an issue of material fact or law is disputed. Id. If issue has been joined, we then look to the moving party's affidavits to determine whether that party has made a prima facie case for summary judgment. Id. If it has, we look to the opposing party's affidavits to determine whether there are any material facts in dispute that entitle the opposing party to a trial. Id. at 372-73.
¶ 50. As part of this summary judgment analysis, we must interpret the EMTALA statute, 42 U.S.C. 1395dd. Statutory interpretation is a question of law that we review de novo. Columbus Park Hous. Corp. v. City of Kenosha, 2003 WI 143, ¶ 9, 267 Wis. 2d 59, 671 N.W.2d 633. When we interpret or apply a statute, we *293attempt to ascertain its meaning in order to give the statute its full intended effect. State ex rel. Kalal v. Circuit Court for Dane County, 2004 WI 58, ¶ 44, 271 Wis. 2d 633, 681 N.W.2d 110. We begin with the words chosen by the legislature, giving them their plain and ordinary meanings. Id., ¶ 45. This is our initial focus, because as we have explained, "[w]e assume that the legislature's intent is expressed in the statutory language." Id., ¶ 44. We are aided in ascertaining the meaning of a statute by the context in which words are placed. Id., ¶ 46. If the statute's meaning is clear on its face, we need go no further; we simply apply it. Id., ¶ 45. However, if the statutory language is capable of being understood by reasonably well-informed persons in two or more ways, then it is ambiguous. Bruno v. Milwaukee County, 2003 WI 28, ¶ 19, 260 Wis. 2d 633, 660 N.W.2d 656. A statute may also be ambiguous due to its interactions with other statutes. State v. White, 97 Wis. 2d 193, 198, 295 N.W.2d 346 (1980). If the statutory language is ambiguous, we may consult extrinsic sources to ascertain legislative intent. Stockbridge Sch. Dist. v. Department of Pub. Instruction Sch. Dist. Boundary Appeal Bd., 202 Wis. 2d 214, 223, 550 N.W.2d 96 (1996).
B. Preston's Claim
¶ 51. The claim at issue here is Preston's claim against Meriter under the screening requirement of EMTALA, 42 U.S.C. 1395dd(a). That provision states:
Medical screening requirement. In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter [42 USCS §§ 1395 et seq.]) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a *294medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.
¶ 52. The majority's discussion of the screening requirement is focused on the meaning of the language "comes to the emergency department" found in 42 U.S.C. 1395dd(a). The majority concludes that:
the proper interpretation of "comes to the emergency department" in this case imposes a duty upon a hospital to provide a medical screening examination to a newborn who (1) presents to the emergency room of the hospital or (2) is born in the birthing center of the hospital and meets the conditions set forth in 42 C.F.R. § 489.24(b) (1999).
Majority op., ¶ 38. The majority further explains that in 42 C.F.R. § 489.24(b), the Department of Health and Human Services (DHHS) has consistently defined the phrase "comes to the emergency department" to include all hospital property. Majority op., ¶ 35. While I agree with the majority's conclusion about the meaning of "emergency department," the majority overlooks the dispositive issue in the present case, which is whether EMTALA applies to inpatients. Because, as I explain below, Bridón was an inpatient rather than someone who "comes to" the hospital, I conclude Preston's claim regarding Bridón falls outside the scope of EMTALA and instead sounds in Wisconsin's medical malpractice law.
¶ 53. There have been no prior decisions directly addressing whether EMTALA's screening requirement applies to inpatients. However, it is only EMTALA's *295screening requirement that is before us on this review. The dearth of cases is not surprising considering that most EMTALA claims do not implicate the unique attributes present in pregnancies, where essentially a "patient with a patient" arrives at the hospital, the expectant mother carrying the unborn child. However, court decisions and federal regulation4 regarding EMTALA's stabilization and transfer requirements, 42 U.S.C. 1395dd(b)-(c),5 shed light on the relation of EMTALA to inpatients.
*296¶ 54. Before the implementation of the DHHS regulation, jurisdictions were split as to whether the stabilization and transfer provisions of EMTALA applied to a patient once he or she was admitted to a hospital. In Thornton v. Southwest Detroit Hospital, 895 P.2d 1131, 1132 (6th Cir. 1990), a patient suffered a stroke, arrived at the hospital's emergency room and spent 10 days in the hospital's intensive care unit and 11 more days in regular inpatient care before being discharged to her sister's home for basic nursing care. The patient brought an action under the stabilization requirement of EMTALA, alleging that the hospital failed to stabilize her before discharging her. Id. The hospital argued that the stabilization requirement did not apply once a patient was admitted to the hospital. Id. at 1135. The Sixth Circuit Court of Appeals disagreed, stating:
Although emergency care often occurs, and almost invariably begins, in an emergency room, emergency care does not always stop when a patient is wheeled from the emergency room into the main hospital. Hospitals may not circumvent the requirements of the Act merely by admitting an emergency room patient to the hospital, then immediately discharging that patient. Emergency care must be given until the patient's emergency medical condition is stabilized.

Id.

¶ 55. In Lopez-Soto v. Hawayek, 175 F.3d 170, 171 (1st Cir. 1999), the patient arrived at the hospital with normal labor pains. The patient was examined and admitted to the maternity ward, where the doctor ordered a cesarean section. Id. The patient gave birth to a baby boy who emerged with severe respiratory and pulmonary problems. Id. The infant was transferred to a hospital with a functioning neonatal intensive care *297unit without first being stabilized, and he later died. Id. The patient brought an action under the stabilization and transfer provisions of EMTALA, arguing that the hospital did not stabilize the infant before transferring him, but the district court dismissed the claim on the ground that the newborn had come to the hospital via the operating room, and EMTALA applied only to entries via the emergency room. Id. at 172. The First Circuit Court of Appeals reversed, concluding that the stabilization and transfer requirements were not limited to entries via the emergency room:
Congress obviously had a horizon broader than the emergency room in mind when it enacted EMTALA. The statute explicitly embraces women in labor, see 42 U.S.C. § 1395dd(e)(l)(B) (defining emergency medical condition) — yet most gravid women go to maternity wards, not emergency rooms, when they are ready to give birth.
. . . Congress's preoccupation with patient dumping is served, not undermined, by forbidding the dumping of any hospital patient with a known, unstabilized, emergency condition. After all, patient dumping is not a practice that is limited to emergency rooms. If a hospital determines that a patient on a ward has developed an emergency medical condition, it may fear that the costs of treatment will outstrip the patient's resources, and seek to move the patient elsewhere. That strain of patient dumping is equally as pernicious as what occurs in emergency departments, and we are unprepared to say that Congress did not seek to curb it.
Id. at 176-77.
¶ 56. However, other jurisdictions concluded that EMTALA's stabilization requirement did not apply to inpatients. In Bryant v. Adventist Health System/West, 289 F.3d 1162, 1164 (9th Cir. 2002), a patient sought *298care at a hospital's emergency room after coughing up blood, and the doctor failed to detect a large lung abscess. The patient was discharged after being diagnosed with pneumonia and asthma, and the doctor requested he return the next day for further treatment. Id. The patient returned the following day, the lung abscess was detected and he was admitted to the hospital. Id. Within three days, the patient's condition declined rapidly, and he was transferred to another hospital, where he had surgery. Id. He later returned home and appeared to be improving, but died suddenly within 10 days of being discharged. Id. The patient's heirs filed an action alleging EMTALA violations concerning both the initial emergency room visit and the subsequent inpatient care. Id. Regarding the inpatient care, the Ninth Circuit Court of Appeals held that "the stabilization requirement normally ends when a patient is admitted for inpatient care." Id. at 1167. The court stated:
The stabilization requirement is ... defined entirely in connection with a possible transfer and without any reference to the patient's long-term care within the system. It seems manifest to us that the stabilization requirement was intended to regulate the hospital's care of the patient only in the immediate aftermath of the act of admitting her for emergency treatment and while it considered whether it would undertake longer-term full treatment or instead transfer the patient to a hospital that could and would undertake that treatment. It cannot plausibly be interpreted to regulate medical and ethical decisions outside that narrow context.
Id. (quoting Bryan v. Rectors & Visitors of the Univ. of Va., 95 F.3d 349, 352 (4th Cir. 1996). The court discussed the Thornton and Lopez-Soto cases, but noted that because "Congress enacted EMTALA 'to create a new cause of action, generally unavailable under state *299tort law, for what amounts to failure to treat' and not to 'duplicate preexisting legal protections'" and that state tort law provided for negligent medical care for inpatients, EMTALA should not apply. Id. at 1168-69 (quoting Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991). The court concluded, "If EMTALA liability extended to inpatient care, EMTALA would be 'converted . . . into a federal malpractice statute, something it was never intended to be.'" Id. at 1169 (quoting Hussain v. Kaiser Found. Health Plan, 914 F. Supp. 1331, 1335 (E.D. Va. 1996).
¶ 57. The Bryant court also addressed the concern in Thornton that hospitals might be able to avoid liability under EMTALA by admitting and then refusing to treat patients. See Thornton, 895 F.2d at 1135. The court stated:
We agree with the [Thornton court] that a hospital cannot escape liability under EMTALA by ostensibly "admitting" a patient, with no intention of treating the patient, and then discharging or transferring the patient without having met the stabilization requirement. In general, however, a hospital admits a patient to provide inpatient care. We will not assume that hospitals use the admission process as a subterfuge to circumvent the stabilization requirement of EMTALA. If a patient demonstrates in a particular case that inpatient admission was a ruse to avoid EMTALA's requirements, then liability under EMTALA may attach.
Bryant, 289 F.3d at 1169.
¶ 58. Similarly, the court in Dollard v. Allen, 260 F. Supp. 2d 1127, 1135 (D. Wyo. 2003), ruled that the stabilization and transfer provisions of EMTALA do not apply to individuals admitted for inpatient care. In that case, the patient periodically visited her doctor for lower back pain and numbness in her buttocks. Id. at *3001129. The problems continued and the patient was admitted to the hospital for pain management and rest. Id. After reporting that the back pain was not as severe, but the numbness had increased, the doctor discharged the patient. Id. at 1130. The next morning the patient began experiencing excruciating pain in her stomach and was unable to urinate. Id. She called the hospital and was readmitted under the care of a new doctor, who determined that the patient had a large ruptured disc in her back, as well as a rare neurological disorder affecting the lower end of the spinal cord. Id. The patient underwent lower-back surgery the day after she was admitted for the second time. Id. The patient filed suit alleging that the hospital violated the screening and stabilization before transfer requirements of EMTALA upon her first admission to the hospital. Id. at 1134. The court granted summary judgment to the hospital on the stabilization and transfer claim on two grounds, one being that the hospital "did not violate EMTALA's stabilization before transfer requirement because that provision does not apply to individuals that have been admitted to the hospital for in-patient care." Id. at 1135. The court stated that allowing EMTALA claims in inpatient situations, where state tort law applied, would "renderf] the Act's preemption subsection superfluous." Id. The preemption provision, 42 U.S.C. 1395dd(f), states, "The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section." The court reasoned that because EMTALA's purpose is to eliminate " 'patient-dumping'" and not to " 'federalize medical malpractice,'" EMTALA does not apply in inpatient situations, where state tort law applies. Dollard, 260 F. Supp. 2d at 1135 (quoting Ingram v. Muskogee Reg'l Med. Ctr., 235 F.3d 550, 552 (10th Cir. 2000).
*301¶ 59. In 2003, as a response to the questions raised by cases such as these, DHHS promulgated a rule "interpreting hospital obligations under EMTALA as ending once the individuals are admitted to the hospital inpatient care." Medicare Program; Clarifying Policies Related to the Responsibilities of Medicare-Participating Hospitals in Treating Individuals With Emergency Medical Conditions, 68 Fed. Reg. 53222, 53244-45 (September 9, 2003) [hereinafter "Clarifying Medicare Policies"]. The rule set out in 42 C.F.R. § 489.24 now states:
Exception: Application to inpatients, (i) If a hospital has screened an individual under paragraph (a) of this section 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 with respect to that individual.
C. 42 C.F.R. § 489.24
¶ 60. Under Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 842-44 (1984), 42 C.F.R. § 489.24 controls regarding the issue of whether EMTALA's stabilization requirement applies to inpatients. Chevron explains how courts are to review an agency's interpretation of a statute. Chevron, 467 U.S. at 842-44. First, we must determine whether the statute at issue is ambiguous regarding the question presented, here, whether EMTALA's requirements apply to inpatients. Id. at 842-43. If we conclude the statute is ambiguous or silent on the issue, our inquiry shifts to determine whether the agency's interpretation is "based on a permissible construction of the statute." Id. We employ one of two tests to make this determination. If Congress explicitly delegated rule-making au*302thority to the agency, then the agency's interpretation is "given controlling weight unless [it is] arbitrary, capricious, or manifestly contrary to the statute." Id. at 843-44; see also United States v. Mead Corp., 533 U.S. 218, 227 (2001). If Congress implicitly delegated authority to the agency, the agency's interpretation controls so long as it is reasonable. Chevron, 467 U.S. at 844.
¶ 61. Applying this analysis to the issue of whether EMTALA covers inpatients, I first note that EMTALA is silent as to this question.6 Therefore, the inquiry shifts to a determination of whether the agency's interpretation in 42 C.F.R. § 489.24 is based on a permissible construction of EMTALA. I agree with the majority that Congress explicitly charged DHHS with the authority to make and publish regulations interpreting EMTALA.7 42 U.S.C. § 1302. Therefore, the interpretation in 42 C.F.R. § 489.24 controls, unless it is arbitrary, capricious or manifestly contrary to the statute.
¶ 62. I conclude the regulation stating that EMTALA's stabilization requirement does not cover inpatients is not arbitrary, capricious, or manifestly contrary to the statute. DHHS drafted proposed regulations and solicited public comments to ensure discussion among interested parties regarding the inpatient issue. In the supplementary information included with the final rule, DHHS includes a lengthy discussion of the issue, including comments made by various parties and DHHS's responses. Clarifying Medicare Policies, supra ¶ 59, at 53243-48. DHSS thoroughly considered these comments, and in response to comments opposed *303to this proposed rule, as well as cases such as Bryant, DHHS ultimately decided to exclude coverage under EMTALA once a person was admitted to the hospital. Id. at 53244-48. Accordingly, DHHS's interpretation cannot be described as arbitrary or capricious.
¶ 63. Because the final regulation advances the purpose of EMTALA, it cannot be described as "manifestly contrary to the statute" either. As discussed in the Bryant and Dollard cases above, EMTALA was designed to "fill the gap" in legal liability for hospitals regarding the failure to treat emergency medical conditions. Given that medical malpractice liability deals with the quality of inpatient treatment, the regulation clarifying that inpatients are not covered by EMTALA merely eliminates possible overlap and retains the protection against "dumping" that EMTALA was created to implement. Therefore, because I conclude that the interpretation of EMTALA in 42 C.F.R. § 489.24 is permissible, it controls regarding whether the stabilization requirement of EMTALA applies to inpatients.
¶ 64. The reasoning that underlies DHHS's regulation in 42 C.ER. § 489.24 applies equally to the screening provision of EMTALA. There is no principled basis to distinguish EMTALA coverage between screening and stabilization procedures for inpatients given that substandard care regarding screening would be subject to a medical malpractice claim just as a substandard effort to stabilize would be. Additionally, the screening requirement is the procedure used to assess whether one who comes to the emergency department should be admitted to the hospital. If the person is already admitted, the purpose that drives the screening requirement has already been met. There*304fore, I conclude that the screening provision of EMTALA does not apply once an individual becomes an inpatient.
¶ 65. I further note that the DHHS regulation controls the present case even though the regulation was not passed until 2003. In Smiley v. Citibank (South Dakota), N.A., 517 U.S. 735, 744 n.3 (1996), the United States Supreme Court responded to the argument that "deferring to the regulation in this case involving antecedent transactions would make the regulation retroactive." The Court stated:
There might be substance to this point if the regulation replaced a prior agency interpretation — which, as we have discussed, it did not. Where, however, a court is addressing transactions that occurred at a time when there was no clear agency guidance, it would be absurd to ignore the agency's current authoritative pronouncement of what the statute means.
Id.; see also Barnhart v. Walton, 535 U.S. 212, 221 (2002) ("[Defendant] also asks us to disregard the Agency's interpretation of its formal regulations on the ground that the Agency only recently enacted those regulations, perhaps in response to this litigation. We have previously rejected similar arguments."). As was the case in Smiley, DHHS promulgated the regulation clarifying the status of inpatients under EMTALA to provide guidance where there had been none, as can be seen in the splits among the various jurisdictions regarding the inpatient issue that existed before the advent of the regulation.
¶ 66. The final issue raised by this case is whether Bridón was an inpatient and therefore, is subject to the previous analysis. It is not disputed that Shannon Preston was admitted shortly after arriving at Meriter, and that she gave birth to Bridón while she was an *305inpatient.8 Preston's unborn child "came to the hospital" at the same time she did.
¶ 67. Care for an unborn child is often required prior to birth, and in providing that care, the unborn child becomes a second inpatient. We have recently held that a pregnant woman and her unborn child are two inpatients during the course of delivery. See Pierce v. Physicians Ins. Co. of Wis., Inc., 2005 WI 14, ¶ 12, 278 Wis. 2d 82, 692 N.W.2d 558 ("we have the unique situation where the patient, Bonnie Pierce, was also the parent of the patient, Brianna Lynn Marcks," who was stillborn). Further support for the contention that a child in útero is an inpatient is shown by the surgery that is performed on unborn children to treat such maladies as spina bifida and lung malformations. See, e.g., Claudia Kalb & Mary Carmichael, Treating the Tiniest Patients, Newsweek, June 9, 2003, at 48; Maggie Jones, A Miracle, and Yet, N.Y. Times, July 15, 2001, § 6 (Magazine), at 39. An unborn child capable of being operated on is an inpatient just as is the mother who carries that child.
*306¶ 68. In this case, Bridón received care before and after his birth. His medical records show that an ultrasound was performed to evaluate the condition of his lungs before he was born. In addition, Bridon's hospital records show he was resuscitated shortly after birth, his heart rate was monitored and he was scored twice, using APGAR.9 Based on these undisputed facts of record, I conclude that Bridón became an inpatient when his mother did, and accordingly, the EMTALA screening requirement does not apply to him. Therefore, I would affirm the court of appeals dismissal of Preston's claim under 42 U.S.C. § 1395dd(a).
II. CONCLUSION
¶ 69. I conclude that the screening provision of EMTALA, 42 U.S.C. § 1395dd(a), does not apply to hospital inpatients. Because Bridón became an inpatient when his mother was admitted before his birth, the screening provision of EMTALA does not apply to him. Therefore, because I would affirm the court of appeals decision dismissing Preston's claim, albeit on different grounds, I respectfully dissent.
¶ 70. I am authorized to state that Justice JON P WILCOX joins this dissent.

 I refer to Shannon Preston, Charles Johnson and the estate of Bridón Michael Johnson collectively as "Preston," unless otherwise noted.

 The dismissal of "all claims" at the circuit court was upon a motion for summary judgment. As a determination of whether the complaint states a claim, the first step in a summary judgment analysis, Brownelli v. McCaughtry, 182 Wis. 2d 367, 372, 514 N.W.2d 48 (Ct. App. 1994), I begin by examining the complaint. This is where the court of appeals stopped in its analysis, as does the majority opinion. See majority op., ¶¶ 5,12, 39 n.12. However, we are not confined to the four corners of the complaint, as we review the summary judgment the circuit court granted.

 All subsequent citations to the United States Code are to the 1994 version unless otherwise noted.

 See 42 C.F.R. § 489.24 (2005), discussed below. All subsequent references to the Federal Register are to the 2005 version unless otherwise noted.

 In addition to the screening requirement at issue in the present case, EMTALA requires hospitals to stabilize the medical condition of patients arriving with an emergency medical condition or in active labor, 42 U.S.C. 1395dd(b), and restricts the transfer of unstabilized patients, 42 U.S.C. 1395dd(c). These provisions state:
(b) Necessary stabilizing treatment for emergency medical conditions and labor.
(1) In general. If any individual (whether or not eligible for benefits under this subchapter [42 USCS §§ 1395 et seq.]) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.
(c) Restricting transfers until individual stabilized.
(1) Rule. If an individual at a hospital has an emergency medical condition which has not been stabilized ... the hospital may not transfer the individual unless [certain conditions are met].

 As I discuss above, the consequences of this silence can be seen in courts' inconsistent application of EMTALA's stabilization requirement to inpatients.

 See majority op., ¶ 27 n.8.

 Paragraph 4 of the complaint alleges that Shannon Preston gave birth "on an emergency basis" to Bridón "while an inpatient" at Meriter. Although Meriter's answer denies "knowledge or information sufficient to form a belief as to the truthfulness of the allegations contained in Paragraphs 1 and 4 of plaintiffs Complaint," this appears to be a denial to the "emergency basis" contention and not the claim that Shannon was an inpatient. Meriter's brief in support of its motion for summary judgment cites the complaint for the contention that Preston was an inpatient, and the affidavit of Peter J. Ouimet, the risk manager for Meriter, in support of motions for judicial determination and to stay discovery, states that Preston was "admitted to the hospital" at about 7:00 p.m. on November 9, 1999. Preston's medical records filed with the affidavit contain a "Nursing Admission Assessment" fisting the time of admission as 7:00 p.m.

 APGAR is a scoring mechanism that evaluates a newborn's vital signs. The acronym stands for: Activity (muscle tone), Pulse, Grimace (reflex irritability), Appearance (skin color) and Respiration. Two points are possible for each criterion. A score of 7-10 is considered normal. See "APGAR Scoring for Newborns," available at http://www.childbirth.org/articles/apgar.html. Bridón scored 1 out of a possible 10 points.