Emergency Medical Treatment and Active Labor Act

The Emergency Medical Treatment and Active Labor Act (EMTALA)[1] is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital Emergency Departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) to individuals seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. There are no reimbursement provisions. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when their condition requires transfer to a hospital better equipped to administer the treatment.[1]

EMTALA applies to "participating hospitals." The statute defines "participating hospitals" as those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program.[2] "Because there are very few hospitals that do not accept Medicare, the law applies to nearly all hospitals."[3] The combined payments of Medicare and Medicaid, $602 billion in 2004,[4] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA's provisions apply to all patients, not just to Medicare patients.[5][6]

The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate.[7] Uncompensated care represents 6% of total hospital costs.[8]

Mandated and non-mandated care

Congress passed EMTALA to eliminate the practice of "patient dumping," i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual seeks treatment for a medical condition "or a request is made on the individual's behalf for examination or treatment for that medical condition."[1]

The U.S. government defines an emergency department as "a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions ."[9] This means, for example, that outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care.[9]

An emergency medical condition (EMC) is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." For example, a pregnant woman with an emergency condition must be treated until delivery is complete unless a transfer under the statute is appropriate.[9]

Patients treated under EMTALA may not be able to pay or have insurance or other programs pay for the associated costs but are legally responsible for any costs incurred as a result of their care under civil law.

Non-covered medical conditions

Not all medical conditions qualify for uncompensated mandated services imposed by EMTALA, which is contrary to the misperception that many individuals assume that if they are ill, they will be treated, regardless of their ability to pay.

The sole purpose for the EMTALA mandated MSE is to require Emergency Departments to make a determination whether an emergency medical condition does or does not exist, using their normal assessment and diagnostic protocols. Since the MSE is a mandated EMTALA service, health insurers are required to cover benefits for their subscribers. They are also required to cover EMTALA mandated services necessary to stabilize individuals determined to have an EMC.

EMTALA intentionally omitted any requirement for hospitals to provide uncompensated stabilizing treatment for individuals with medical conditions determined not to be an EMC. Therefore, such individuals are not eligible for further uncompensated examination and treatment beyond the MSE.

Examples of conditions not considered emergencies by courts or hospitals

A significant portion of emergency room visits are considered not to be EMCs as defined by EMTALA. The medical profession refers to these cases as "non-emergent". Regardless, this impressive term is not recognized by the law as a condition defined by the EMTALA statute. A term more relevant for compliance with EMTALA is non-emergency medical condition. If this "non-emergent" term is used in the context of EMTALA, it needs to be defined as medical conditions that fail to pass the criteria for determination of being a true EMC as defined by EMTALA statute.

If a patient is already in the hospital for another reason and develops an emergency condition, EMTALA similarly does not apply.[10]

Hospital obligations

Hospitals have three obligations under EMTALA:

  1. Individuals requesting emergency care, or those for whom a representative has made a request if the patient is unable, must receive a medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists. The participating hospital cannot delay examination and treatment to inquire about methods of payment or insurance coverage, or a patient's citizenship or legal status. The hospital may only start the process of payment inquiry and billing once they have ensured that doing so will not interfere with or otherwise compromise patient care.
  2. When an Emergency Department determines an individual has an EMC, they must provide further treatment and examination until the EMC is resolved or stabilized and the patient is able to provide self-care following discharge, or if unable, can receive needed continual care. Inpatient care provided must be at an equal level for all patients, regardless of ability to pay. Hospitals may not discharge a patient prior to stabilization if the patient's insurance is canceled or otherwise discontinues payment during course of stay.
  3. If the hospital does not have the capability to treat the condition, the hospital must make an "appropriate" transfer of the patient to another hospital with such capability. This includes a long-term care or rehabilitation facilities for patients unable to provide self-care. Hospitals with specialized capabilities must accept such transfers and may not discharge a patient until the condition is resolved and the patient is able to provide self-care or is transferred to another facility.

REMINDER: Hospitals have no obligation under EMTALA to provide uncompensated services beyond the MSE to individuals determined not to have an EMC.

Amendments

Since its original passage, Congress has passed several amendments to this act. Additionally, state and local laws in some places have imposed additional requirements on hospitals. These amendments include the following:

Effects

Improved health services for uninsured

The most significant effect is that, regardless of insurance status, participating hospitals are prohibited from denying a MSE to individuals seeking treatment for a medical condition. Currently EMTALA only requires that hospitals stabilize the EMC. According to some analyses of the U.S. health care safety net, EMTALA is an incomplete and strained program.[11][12]

Cost pressures on hospitals

According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated.[13] When medical bills go unpaid, health care providers must either shift the costs onto those who can pay or go uncompensated. In the first decade of EMTALA, such cost-shifting amounted to a hidden tax levied by providers.[14] For example, it has been estimated that this cost shifting amounted to $455 per individual or $1,186 per family in California each year.[14]

However, because of the recent influence of managed care and other cost control initiatives by insurance companies, hospitals are less able to shift costs, and end up writing off more in uncompensated care. The amount of uncompensated care delivered by non-federal community hospitals grew from $6.1 billion in 1983 to $40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured,[13] but it is unclear what percentage of this was emergency care and therefore attributable to EMTALA.

Financial pressures on hospitals in the 20 years since EMTALA's passage have caused them to consolidate and close facilities, contributing to emergency room overcrowding.[15] According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425.[16] Ambulances are frequently diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances were diverted over a half a million times, not necessarily due to patients' inability to pay.[16]

See also

Notes and references

  1. 1 2 3 42 U.S.C. § 1395dd
  2. ↑ 42 U.S.C. § 1395dd (e)(2) The term "participating hospital" means a hospital that has entered into a provider agreement under section 42 U.S.C. § 1395cc of this title.
  3. ↑ Emergency Medical Treatment and Active Labor Act summary, Families USA.
  4. ↑ Key Medicare and Medicaid Statistics from kff.org
  5. ↑ Text of act from law.cornell.edu
  6. ↑ EMTALA FAQ Website / Information from Garan Lucow Miller, P.C
  7. ↑ Fact Sheet: EMTALA from the American College of Emergency Physicians accessed 2007-11-01
  8. ↑ American Hospital Association, Trends Affecting Hospitals and Health Systems 2011, Chapter 4, Slide 7
  9. 1 2 3 American College of Emergency Physicians: EMTALA Fact Sheet, accessed 2007-10-05.
  10. 1 2 http://www.nursinglaw.com/emtala8.htm
  11. ↑ Catherine Hoffman and Susan Starr Sered (November 2005). "Threadbare: Holes in America's Healthcare Safety Net" (PDF). The Kaiser Commission on Medicaid and the Unisured. Retrieved 2007-10-22. Health conditions that are not immediately life-threatening, but urgent and should be managed initially by specialists, fall through the holes in the safety net.
  12. ↑ "Report Brief. America's Health Care Safety Net: Intact but Endangered" (PDF). Institute of Medicine, National Academies of Science. 2000-01-01. Retrieved 2007-10-22. In the absence of universal health insurance, a health care “safety net” is the default system of care for many of the 44 million low-income Americans with no or limited health insurance as well as many Medicaid beneficiaries and people who need special services. This safety net system is neither uniformly available throughout the country nor financially secure.
  13. 1 2 The Uninsured: Access to Medical Care, American College of Emergency Physicians, accessed 2007-10-05
  14. 1 2 (Peter Harbage and Len M. Nichols, Ph.D., "A Premium Price: The Hidden Costs All Californians Pay In Our Fragmented Health Care System," New America Foundation, 12/2006)
  15. ↑ http://www.washingtonpost.com/national/health-science/medstar-washington-hospital-center-to-cut-more-than-200-jobs-due-to-financial-woes/2013/11/11/913dfbd4-4afe-11e3-9890-a1e0997fb0c0_story.html
  16. 1 2 Fact Sheet: The Future of Emergency Care: Key Findings and Recommendations, Institute of Medicine, 2006, accessed 2007-10-07.

External links

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