Health Policy

All About EMTALA: The Law That Runs the ED

EMTALA was meant to ensure emergency care for all. While it has provided that type of safety net, some unintended consequences have not been as positive.

Enacted by Congress in 1986, the Emergency Medical Treatment and Labor Act (EMTALA) was designed to provide emergency care to all patients, regardless of insurance status or ability to pay. But some of the unintended consequences of EMTALA have not been as positive.

EMTALA defines 3 responsibilities of participating hospitals (defined as hospitals that accept Medicare reimbursement):1 

  1. Provide all patients with a medical screening examination (MSE)
  2. Stabilize any patients with an emergency medical condition
  3. Transfer or accept appropriate patients as needed

Responsibilities of Hospitals and Providers
1. Medical Screening Examination
According to EMTALA, all patients, regardless of insurance status, nation of origin, race, religion, etc., are entitled to an MSE if they are on a "hospital campus" (within 250 yards of a hospital building). The purpose of the MSE is "to determine whether or not an underlying emergency medical condition exists."2

2. Stabilization
If the MSE reveals an emergent condition, EMTALA mandates that the hospital stabilize the patient, meaning you are reasonably sure they can be transferred or discharged without clinical deterioration. Of course, stabilizing a patient often requires other consultants, which means the EMTALA requirements — and penalties — extend to them as well.

3. Transfers
EMTALA also requires that hospitals perform an "appropriate transfer" to a higher level of care if required by the patient's condition. To satisfy this aspect of the law, the transferring hospital must treat and stabilize the patient to the fullest extent of its resources, provide care en route, contact the receiving hospital (who has agreed to accept the patient), and transfer the patient with appropriate copies of medical records. (Transferring a patient without copies of the medical record, including imaging, is an EMTALA violation.)3 Correspondingly, the law mandates that the receiving hospital accept the patient, as long as it has the appropriate resources to care for the patient.

Penalties
EMTALA is tied to Medicare reimbursement, and severe violations can lead to termination of the hospital or provider's Medicare Provider Agreement. Fines can reach $100,000 per violation, and hospitals may be held liable for civil lawsuits, either from patients or from transferring or receiving hospitals.

Consequences
The law has ensured that all patients can receive the emergency care they need, which has transformed the ED into society's de facto safety net. Our specialty's ability to treat anyone, with anything, at any time4 fits EMRA's position that "all individuals should have access to quality, affordable primary and emergency health care services."5 Unfortunately, these benefits have not come without cost.

U.S. hospitals provided $38.4 billion in uncompensated care in 2017.6 That number decreased slightly after passage of the Affordable Care Act (ACA), but has worsened since then. The ACA was designed to eliminate uncompensated care, but the reluctance of some states to expand Medicaid has hampered those efforts, and states that have expanded Medicaid have seen a bigger drop in uncompensated care than those that haven't.7

Resistance to Medicaid expansion is not the only threat to hospital finances due to uncompensated care.8 Many insurers are now implementing policies to reduce reimbursement for ED visits retroactively deemed to be non-emergent. In an age where 40% of health insurance plans are considered high deductible,9 this policy threatens to increase the amount of care that hospitals (and particularly EDs) provide without reimbursement.

Hospitals have been closing at alarming rates across the country, especially in rural America. Many have cited uncompensated care as a cause of hospital closures.10

Bottom Line for EM Residents
Emergency physicians treat any patient with any emergent condition regardless of other factors, as EMTALA mandates. Stabilizing and transferring patients appropriately are aspects of the law, and should also be aspects of good patient care. But while EMTALA has helped our patients and society, it has also put a significant financial burden on hospitals. We need to keep pushing against policies that increase uncompensated care, so that we can continue to care for any one, with anything, and any time.


References
1. TenBrink W, O’Sullivan E, Dhaliwal R, Dodd K. The Impact of EMTALA. In: Schlicher N, Haddock A, eds. Emergency Medicine Advocacy Handbook. 5th ed. Dallas, TX: EMRA; 2019:21-28.
2. 42 CFR § 498.24 (a).
3. Christiansen CR, Davlantes E. EMTALA: Things You Never Knew (Or Never Thought to Ask). EM Resident. 2016;43(2):6-7.
4. Zink B. Anyone, Anything, Anytime – A History of Emergency Medicine. 2017.
5. EMRA. Policy Compendium. April 2019.
6. American Hospital Association. AHA Annual Survey Data. 2017.
7. Dranove D, Garthwaite C, Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of the Repeal. The Commonwealth Fund; 2017.
8. Gettel C, Kharel R, Samuels EA. Non-Emergent Visits and Challenges to the Prudent Layperson Standard. In: Schlicher N, Haddock A, eds. Emergency Medicine Advocacy Handbook. 5th ed. Dallas, TX: EMRA; 2019:35-40.
9. Cohen RA, Zammitti EP. High-deductible Health Plans and Financial Barriers to Medical Care: Early Release Estimates from the National Health Interview Survey, 2016. National Center for Health Statistics. 2017.
10. Lindrooth RC, Perraillon MC, Hardy RY, Tung GJ. Understanding the Relationship Between Medicaid Expansions and Hospital Closures. Health Aff (Millwood). 2018;37(1):111-120.
11. Joynt KE, Chatterjee P, Orav EJ, Jha AK. Hospital Closures Had No Measurable Impact on Local Hospitalization Rates or Mortality Rates, 2003-11. Health Aff (Millwood). 205;34(5):765-772.
12. Chou S, Deily ME, Li S. Travel distance and health outcomes for scheduled surgery. Med Care. 2014;52(3):250-257.

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