The Emergency Medical Treatment and Labor Act is a Federal law enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd). Referred to as the “anti-dumping” law, it was designed to prevent hospitals from refusing to treat patients or transferring them to charity or public hospitals because they were unable to pay or had Medicaid coverage. EMTALA requires hospitals with emergency departments to provide emergency medical care to everyone who needs it, regardless of ability to pay or insurance status. Under the law, patients with similar medical conditions must be treated consistently. The law applies to hospitals that accept Medicare reimbursement, and to all their patients, not just those covered by Medicare.
Hospitals have three basic obligations under EMTALA
No further EMTALA obligations exist if an appropriate medical screening examination identifies no emergency medical condition. No further EMTALA obligations exist if an identified emergency medical condition is stabilized. Additionally, the latest regulations now recognize that a patient with an emergency medical condition may be discharged with a plan to have subsequent treatment provided as an outpatient if such a plan is consistent with medical routine and does not jeopardize the patient’s health.
EMTALA governs how patients may be transferred from one hospital to another. Under the law, a patient is considered stable for transfer if the treating physician determines no material deterioration will occur during the movement between facilities and that the receiving facility has the capacity to manage the patient’s medical condition. EMTALA does not control the transfer of stable patients; however, patients with incompletely stabilized emergency medical conditions still may be transferred under EMTALA if one of two conditions exists, as follows:
Once a decision is made to transfer the individual, the following steps must be taken:
Under EMTALA, patient care during transport is the responsibility of the transferring physician/hospital, until the patient arrives at the receiving facility. The transferring physician is also responsible for the order to transfer and for the treatment orders to be followed during the transport. This may conflict with State statutes, which in some instances, allow only authorized medical direction physicians to give orders to EMS personnel. EMTALA does not reference the transport service and its medical director, leaving ultimate medical responsibility and its transition during transport open for interpretation.
The legislation poses several additional complexities for individual hospitals and for an integrated EMS system in which transfers can play a considerable role:
As the scope of EMTALA has widened in an effort to make the law more effective, existing weaknesses in the delivery of care have created new problems.
In the binding regulations published in 1994, the requirements for basic screening and stabilization pertained to patients anywhere on hospital property, including ambulances owned and operated by the hospital.
Since EMTALA was enacted, the national ED patient volume has increased and during the same time period, the number of hospital EDs has declined. As a result, fewer resources are available to meet an increasing legal obligation.
The discussion in the interpretive guidelines and case law obligated a hospital to accept an unstable patient if it has the capacity and has any equipment that the patient’s condition requires that the referring hospital lacks. This disproportionately expands the obligations of EDs with more sophisticated capabilities, and increases the obligations placed on on-call physicians. Although EMTALA obligates hospitals to have a roster of on-call physicians who can complete medical screening examinations and provide stabilization for the services the hospital offers to its community, many hospitals are not able to fill their on-call rosters.
A recent decision by a Federal appeals court concluded that a patient coming to the ED triggers EMTALA obligations not only when the patient is on hospital property, but also while traveling toward the hospital. So, even when the decision to divert ambulance patients is reasonable, the ED may still be liable for EMTALA violation.
As providers grapple with new burdens, they confront difficult challenges that are a logical consequence of those new responsibilities. The net impact of these changes has resulted in a decrease in the availability of the services that the law was intended to promote.