United States Court of Appeals
For the First Circuit
No. 03-2256
JOAN RODRIGUEZ; DOMINGO DIAZ ROJAS; CONJUGAL PARTNERSHIP DIAZ-
RODRIGUEZ,
Plaintiffs, Appellees,
v.
AMERICAN INTERNATIONAL INSURANCE COMPANY OF PUERTO RICO;
CORPORACION DE SERVICIOS INTEGRALES DE SALUD DEL AREA DE
BARRANQUITAS, COROZAL, NARANJITO Y OROCOVIS,
Defendants, Appellants.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Jaime Pieras, Jr., Senior U.S. District Judge]
Before
Torruella, Lynch, and Lipez, Circuit Judges.
Jeannette López de Victoria, with whom Pinto-Lugo, Oliveras &
Ortiz, PSC was on brief, for appellants.
Ramon L. Walker Merino, with whom Walker Merino Law Office was
on brief, for appellees.
March 23, 2005
LYNCH, Circuit Judge. The question presented is whether
a regional diagnostic and treatment center which treats only
ambulatory patients and has an emergency room independent of a
hospital is subject to the requirements of the Emergency Medical
Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd.
The district court, ruling on a suit by the parents of a
four-month old baby girl who died after being seen in the emergency
room of a Diagnostic and Treatment Center ("Centro de Diagnóstico
y Tratamiento") ("CDT") in Corozal, Puerto Rico, held that an
EMTALA suit was actionable. We accepted the district court's
certification of this dispositive issue of law for interlocutory
appeal pursuant to 28 U.S.C. § 1292(b). We reverse, and order
dismissal of the suit.
I.
The plaintiffs, a married couple, had a daughter, Lilliam
Diaz Rodriguez, who was born on October 10, 2000, with a
combination of congenital cardiovascular defects which made her
prone to cyanosis.
Lilliam vomited twice on March 3, 2001, and was taken by
her mother to the emergency ward at the Corozal CDT at 9:00 PM for
respiratory difficulties. The emergency ward doctor at the CDT
decided to transfer the child to the Pediatric Hospital at the
Puerto Rico Medical Center and inserted an endotracheal tube in
Lilliam. At 2:00 AM the next morning the child was transported to
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the Puerto Rico Medical Center with generalized cyanosis, and
Lilliam died sometime after arriving there.
The plaintiffs filed a federal suit for damages against
Corporacion de Servicios Integrales de Salud del Area de
Barranquitas, Corozal, Naranjito y Orocovis ("Corporacion"), the
owner of the Corozal CDT, and American International Insurance
Company of Puerto Rico ("AIICO"), Corporacion's insurer.1 The
plaintiffs asserted federal subject matter jurisdiction by alleging
that the defendants violated EMTALA by failing to provide the child
with an "appropriate medical screening examination" so as to detect
her emergency condition and by failing to stabilize the child's
condition properly before transferring her. See 42 U.S.C. §
1395dd(a)-(c). The complaint also alleged a Puerto Rico law claim
of medical malpractice by the defendants, and invoked the federal
court's supplemental jurisdiction.
The defendants moved for summary judgment. The
defendants, inter alia, denied the existence of federal subject
matter jurisdiction, contending that EMTALA does not apply to the
allegations in the complaint because the Corozal CDT is not a
"hospital" within the meaning of EMTALA.
1
The plaintiffs also named Aeromed Services, Inc., which
provided the ambulance transportation from the Corozal CDT to the
Puerto Rico Medical Center, as a defendant. Aeromed is not
involved in this appeal.
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The district court denied the defendants' motion for
summary judgment on May 9, 2003. In its Opinion and Order, the
district court concluded that "the provisions of EMTALA apply to
CDTs in Puerto Rico that offer twenty-four hour emergency room
services, and that consequently, Plaintiffs have a colorable claim
under said statute."
The defendants then sought to certify the district
court's order for interlocutory appeal. After initially denying
the motion, the district court ultimately certified the
jurisdictional issue of whether the provisions of EMTALA are
applicable to CDTs for consideration before this court. Pursuant
to 28 U.S.C. § 1292(b), this court allowed the interlocutory appeal
after both appellants and appellees stipulated that the following
facts are not disputed:
1. The Corozal CDT is licensed under Puerto
Rico law to operate as a diagnostic and
treatment center.
2. The Corozal CDT provides 24-hour emergency
room services.
3. The Corozal CDT has executed a Medicare
Provider "Part B" agreement.
4. The Corozal CDT is not a hospital-based
facility nor is it attached to a hospital.
5. The Corozal CDT is not an inpatient
facility.
II.
We review de novo the grant or denial of summary
judgment, Univ. Emergency Med. Found. v. Rapier Invs., Ltd., 197
F.3d 18, 20 n.4 (1st Cir. 1999), as well as pure issues of law,
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Rational Software Corp. v. Sterling Corp., 393 F.3d 276, 276 (1st
Cir. 2005).
In 1986 Congress enacted EMTALA in large part to solve
the problem of "dumping" of uninsured patients -- the problem of
hospital emergency rooms refusing to treat or transferring indigent
patients to public hospitals without first assessing and/or
stabilizing the patient's condition. See Correa v. Hosp. San
Francisco, 69 F.3d 1184, 1189 (1st Cir. 1995). EMTALA imposed some
limited substantive requirements on emergency rooms of hospitals
participating in the federal Medicare program. Specifically EMTALA
requires (1) that "a participating hospital afford an appropriate
medical screening to all persons who come to its emergency room
seeking medical assistance," and (2) "if an emergency medical
condition exists, the participating hospital must render the
services that are necessary to stabilize the patient's condition .
. . unless transferring the patient to another facility is
medically indicated and can be accomplished with relative safety."
Id. at 1190; 42 U.S.C. § 1395dd(a)-(c).
EMTALA created a private cause of action for damages for
violations of the Act against "participating hospitals." 42 U.S.C.
§ 1395dd(d)(2)(A). Congress conditioned those hospitals' continued
participation in the federal Medicare program on acceptance of the
duties imposed by EMTALA, "[n]eeding a carrot to make health-care
providers more receptive to the stick." Correa, 69 F.3d at 1189.
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The question of law posed by this case is whether a CDT,
defined by Puerto Rico law as "an independent facility . . . which
provides community services for the diagnosis and treatment of
ambulatory patients under the professional supervision of persons
licensed to practice medicine, surgery or dentistry in Puerto
Rico," 24 P.R. Laws Ann. § 331a(A)(4),2 qualifies as "a hospital
that has a hospital emergency department" under EMTALA, 42 U.S.C.
§ 1995dd(a).3 It is undisputed that the Corazal CDT is an
2
The full definition of a CDT is "an independent facility or
one operated in conjunction with a hospital which provides
community services for the diagnosis and treatment of ambulatory
patients under the professional supervision of persons licensed to
practice medicine, surgery or dentistry in Puerto Rico." 24 P.R.
Laws Ann. § 331a(A)(4). There is no dispute over the fact that the
Corozal facility is not operated in conjunction with a hospital.
3
In relevant part, EMTALA provides:
In the case of a hospital that has a hospital
emergency department, if any individual
(whether or not eligible for benefits under
this subchapter) comes to the emergency
department and a request is made on the
individual's behalf for examination or
treatment for a medical 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) of this section)
exists.
42 U.S.C. § 1395dd(a). The enforcement provision is limited to
"participating hospital[s]." Id. § 1395dd(d)(2)(A). A
"participating hospital" is in turn defined as "a hospital that has
entered into a [Medicare] provider agreement under section 1395cc
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independent facility and is not attached to a hospital. CDTs are
"unique" to Puerto Rico and are "limited health facilities that
offer only outpatient services such as dentistry, X-ray, and
laboratory services."
It is clear that EMTALA does not apply to all health care
facilities; it applies only to participating hospitals with
emergency departments.4 Further, the screening requirement under
of this title." Id. § 1395dd(e)(2). The plaintiffs' reliance on
this definition to establish that the CDT is a hospital is
misplaced. The existence of a Medicare provider agreement is
relevant to whether a facility is "participating" for EMTALA
purposes, not to whether a facility is a hospital. Revisions to
section 1395cc, which defines the Medicare provider agreements, are
not relevant to the issues in this case.
4
The plaintiffs attempted at oral argument to bolster their
argument by pointing to amendments to an EMTALA regulation, 42
C.F.R. § 489.24. The regulation was amended after the filing of
this suit and the issuance of the district court's order. See 68
Fed. Reg. 53222, 53262 (Sept. 9, 2003). It now includes a
definition for "dedicated emergency department":
Dedicated emergency department means any
department or facility of the hospital,
regardless of whether it is located on or off
the main hospital campus, that meets at least
one of the following requirements:
(1) It is licensed by the State in which it
is located under applicable State law as an
emergency room or emergency department;
(2) It is held out to the public (by name,
posted signs, advertising, or other means) as
a place that provides care for emergency
medical conditions on an urgent basis without
requiring a previously scheduled appointment;
or
(3) During the calendar year immediately
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EMTALA only applies to patients seeking treatment at the emergency
room, not elsewhere in a hospital. See Lopez-Soto v. Hawayek, 175
F.3d 170, 173 (1st Cir. 1999); Baber v. Hosp. Corp. of Am., 977
F.2d 872, 884 (4th Cir. 1992). It follows that if the Corozal CDT
is not a "hospital," EMTALA cannot apply to it.
As an amendment to the Social Security Act, EMTALA
incorporates the Act's definition of a "hospital." See Jackson v.
East Bay Hosp., 246 F.3d 1248, 1260 (9th Cir. 2001); cf. Correa, 69
F.3d at 1196 (looking to the Social Security Act's definition of
"state law" as the term is used in EMTALA). That definition of
"hospital" set forth in 42 U.S.C. § 1395x includes, in relevant
part:
(e) Hospital. The term "hospital" . . . means
an institution which -
(1) is primarily engaged in providing, by
or under the supervision of physicians,
to inpatients (A) diagnostic services
preceding the calendar year in which a
determination under this section is being
made, based on a representative sample of
patient visits that occurred during that
calendar year, it provides at least one-third
of all of its outpatient visits for the
treatment of emergency medical conditions on
an urgent basis without requiring a previously
scheduled appointment.
42 C.F.R. § 489.24(b). The plaintiffs argue that this definition
means that the emergency room need not be a part of the hospital,
but can be "off campus." The amended regulation is irrelevant to
the issue, and in any case this argument misconstrues the
regulation. The "dedicated emergency department" may be physically
located off campus from the main hospital building, but it still
must be a part of a hospital.
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and therapeutic services for medical
diagnosis, treatment, and care of
injured, disabled, or sick persons, or
(B) rehabilitation services for the
rehabilitation of injured, disabled, or
sick persons;
. . .
(7) [and,] in the case of an institution in
any State in which State or applicable
local law provides for the licensing of
hospitals, (A) is licensed pursuant to
such law or (B) is approved, by the
agency of such State or locality
responsible for licensing hospitals, as
meeting the standards established for
such licensing . . . .
42 U.S.C. § 1395x(e). The Corozal CDT plainly does not meet these
requirements, for at least two reasons. First, it is not primarily
engaged in providing diagnostic and therapeutic or rehabilitation
services to inpatients, as required by subsection (e)(1). The CDT
is engaged entirely in outpatient, ambulatory care.
Second, even if the requirement of subsection (e)(1) were
met, the other requirements of subsection (e)(7) must be met as
well. Puerto Rico law does not license or characterize CDTs as
hospitals. Indeed, Puerto Rico law clearly distinguishes between
hospitals and diagnostic and treatment centers. Compare 24 P.R.
Laws Ann. § 331a(A)(1) (defining a "hospital" as "an institution
which renders services to the community providing medical and/or
surgical diagnosis and/or treatment for illnesses or injuries
and/or obstetric treatment to hospitalized patients . . ."
(emphasis added)), with 24 P.R. Laws. Ann. § 331a(A)(4) (defining
a CDT as "an independent facility or one operated in conjunction
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with a hospital which provides community services for the diagnosis
and treatment of ambulatory patients under the professional
supervision of persons licensed to practice medicine, surgery or
dentistry in Puerto Rico" (emphasis added)). Even if a CDT
provides emergency services, that does not make it an emergency
room of a participating hospital.
The district court recognized that "under normal
circumstances, the Court would agree that a clinic, which is really
what a CDT is more akin to, does not fall under the auspices of
EMTALA." As a result, the district court found:
[T]his case hinges not on the literal wording
of the statute, but rather on the end result -
- that the services provided by Defendant are
the types of services that this law is clearly
geared to cover. The statute is clear in the
nature of the services it pertains to: it
applies to emergency rooms, a facility that
has traditionally provided 24-hour services
identical to the one in the case at bar.
The district court found it would be "unconscionable" not to extend
EMTALA to cover CDTs with 24-hour emergency services because that
would have the effect of "excluding the poor population who
primarily rely on CDT services from the reaches of this all
important law." So, it concluded, the spirit of EMTALA, if not its
letter, was meant to cover the action against the defendants.
The district court erred. Federal courts are not free to
ignore the letter of the law in favor of the "spirit" of a law.
"[C]ourts interpret statutes primarily through detailed analysis of
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concrete statutory language, not by reference to abstract notions
of generalized legislative intent." Lopez-Soto, 175 F.3d at 176.
"[C]ourts must presume that a legislature says in a statute what it
means and means what it says there." Connecticut Nat'l Bank v.
Germain, 503 U.S. 249, 253-54 (1992). There is no legal ambiguity
about the language Congress used in EMTALA -- EMTALA requires the
emergency room be of a participating hospital. There is no factual
issue about whether the defendant is an emergency room of a
hospital -- it is not. The fact that the CDT receives Medicare
funds does not make it an emergency room of a hospital.
Congress attempted to solve one problem -- to stop the
dumping of indigent patients by hospital emergency rooms -- and
chose language to effectuate its ends. That type of problem is not
presented by the facts of this case. It is up to Congress, if it
so wishes, to extend the protection of EMTALA to other situations.
It has not chosen to do so.
The denial of summary judgment to the defendants is
reversed and the federal claims are ordered dismissed with
prejudice. There being no basis for federal jurisdiction
otherwise, the district court is directed to dismiss the Puerto
Rican law claims without prejudice. No costs are awarded.
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