Yesterday, a man was shot a couple of miles from our hospital. Not an unusual event, people get shot every day in America's large cities. Our hospital is not a designated trauma...
The EMTALA law was enacted 33 years ago as an “anti-dumping” law. EMTALA fundamentally has 2 main implications for the hospital: how you manage patients in the emergency room and how you manage hospital transfers. It stands for the Emergency Medical Treatment and Active Labor Act and it placed requirements on hospitals receiving Medicare payments; because almost all hospitals accept Medicare, in practice, it affects nearly all U.S. hospitals.
There are 3 obligations that hospitals have under EMTALA:
- The emergency department must provide a medical screening exam to any patient who requests emergency care, regardless of their health insurance status, their ability to pay, or their citizenship.
- If the medical screening exam indicates that the patient has an emergency medical condition, then the hospital must provide treatment until the condition resolves or stabilizes and the patient can provide self-care after discharge.
- If the hospital does not have the capability to treat the patient’s condition, then it must make an appropriate transfer to another hospital that has the capability of treating the patient’s condition and provide medical records to the accepting hospital. Hospitals with specialized capabilities must accept these transfers and provide treatment.
Why did EMTALA come to be?
In the 1980’s, some hospitals and doctors flat out refused to treat patients in their emergency departments if the patients could not pay. Other hospitals would transfer unstable patients to public hospitals without doing even a basic medical assessment or providing initial treatment to stabilize patients. Physicians at Cook County Hospital in Chicago reported that 87% of patients transferred to their hospital were sent because they lacked health insurance, only 6% of those patients actually gave written consent for transfer, and 24% were transferred in medically unstable condition. Thus emerged the term “patient dumping”. A 1985 exposé on the CBS news show 60 Minutes titled “The Billfold Biopsy” helped raise public awareness of the national scope of the problem.
But if you look a bit closer, EMTALA was, at least in part, designed to protect Medicare patients. Three years earlier, congress had enacted legislation that created DRGs, meaning that hospitals got paid based on the diagnosis rather than being paid based on charges. Legislators were concerned that hospitals would try to game the DRG system by providing substandard care to reduce costs in order to profit by DRG payments by Medicare. EMTALA directly addressed this by requiring hospitals to provide the same emergency care to patients whether they had commercial insurance or Medicare/Medicaid.
What about free-standing emergency rooms?
EMTALA applies to hospital emergency rooms, whether they are physically part of the hospital building or geographically separated from the hospital. In the past 15 years, there has been a nationwide proliferation of free-standing emergency rooms that are located many miles away from its parent hospital, generally in suburban areas. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. So why do hospitals build satellite emergency departments in the suburbs? Because that is where the money is – lots of commercially insured patients with relatively fewer Medicaid and uninsured patients. These outlying emergency rooms can serve as conduits to direct well-insured patients needing profitable surgeries or inpatient admissions to the host hospital. This type of free-standing emergency room is subject to EMTALA requirements just as if they were physically attached to the host hospital.
There is a second type of free-standing emergency room. These are privately-owned and not associated with a local hospital. Currently, there is uncertainty about whether these facilities fall under the EMTALA requirements and there are state-specific laws and legal precedents about whether or not they must adhere to all of the elements of EMTALA. However, since these emergency rooms are not associated with a hospital, they cannot provide inpatient treatment for emergency medical conditions and so the emergency room physicians can transfer a patient requiring inpatient care to any hospital they choose.
What are the implications for physicians?
The focus of EMTALA was initially on emergency room physicians – that they must do a medical screening exam and provide basic emergent care to all patients. However, when I am on call at night for our intensive care units, EMTALA also applies to my decision making. As a tertiary care medical center, our ICU has the capability of providing a higher level of care than most other ICUs in the region. Many hospitals lack critical care physicians, infectious disease specialists, cardiothoracic surgeons, and other specialists. Because we have residents, nurse practitioners, and fellows in our various ICUs at night to handle most patient care-related calls, the most common calls I get are from other hospitals asking about transferring patients to our medical intensive care units. If we have empty ICU beds, we are usually obligated to take those critically ill patients. However, despite EMTALA being decades old, I am still called by outlying emergency room physicians about transferring uninsured patients purely because the physician considers ours to be a charity hospital since we are a state-supported university. It can often be a fine line to walk: we are obligated to accept in transfer any patient whose medical needs cannot be met at these outlying hospitals but we are not obligated to accept patients simply because they are uninsured. Experienced attending emergency room physicians know about EMTALA requirements but the questionable calls most commonly come from residents in training or junior attending physicians in ERs at hospitals that are part of a larger healthcare system that includes tertiary care hospitals. These less-experienced physicians often do not realize their (and their hospital’s) requirements under EMTALA and as a consequence, “patient dumping” to academic medical centers still occurs.
Overall, EMTALA has improved the care to vulnerable patient populations. But EMTALA is still just as important today as it was 33 years ago and it is incumbent on us to insure that our emergency room physicians, our hospitalists, and our critical care physicians understand EMTALA’s implications for their clinical practices.
October 28, 2019