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Effects of EMTALA on Healthcare

JL Admin

Executive Summary:

On August 29, 2003, the Center for Medicare & Medicaid Services (CMS) published the revised EMTALA obligations for the perusal of hospitals and doctors. In summary, these regulations try to define the cases where EMTALA is applicable, and also the circumstances and situations that warrant its application. The statutes framed therein define the obligations of various parties in a variety of emergency situations and conditions.  In effect, the statutes

Effects of EMTALA on Healthcare

The Emergency Medical Treatment and Active Labor Act (EMTALA) is an important legislation that governs a healthcare professional’s code of conduct in dealing with a patient in an Emergency Room.  It defines the conditions and circumstances under which a patient may be denied treatment or transferred to another hospital.

The EMTALA is part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) that was passed in 1986.  EMTALA has a broad range of implications that determines the provisions of emergency care treatment for patients, including the ones who are registered under Medicare.  It has to be remembered that EMTALA is applicable only to hospitals and other medical centers that have entered into “provider agreements” with the Federal government.  The Federal government agency The Department of Health and Human Services provides payment to these hospitals for treatment provided to patients enrolled with their program.  Since a majority of the American demography are beneficiaries of one program or the other offered by this government agency, hospital managements don’t have an option other than adopting EMTALA rules and regulations in dealing with patients (Rosenbaum, 2003).  So, when hospitals are bound by the EMTALA, they cannot overlook patient needs in favor of monetary gains.  In other words, patients needing critical care and immediate attention cannot be turned away or directed to other hospitals just because they are not in a position to pay for the services.  In this sense, the Act can also be interpreted as a “non-discrimination statute”.  The Act ensures that patients who are subscribed to government insurance programs get all the benefits that are afforded by private insurance programs (Westfall, 2003).

Some of the essential provisions under EMTALA are as follows:

  1. All patients who are brought to a hospital under an emergency situation should be properly screened so as to determine the exact nature and intensity of their medical condition.  If the condition is deemed an emergency, then the patient “should” be provided with all necessary care that is required at that moment.  Only when the patient recovers to a state of stability can the hospital management delve into such matters as his/her health insurance, etc.  If the results of the screening examination don’t term the condition as an emergency, then the hospital is allowed to act as per its internal policies.
  2. In case the patient being brought in is a woman in active labor, then it is imperative on part of the hospital to cater to all the needs of the patient till she delivers (Bristol, 2006).

There are some other technical qualifiers attached with EMTALA.  One such is that the screening examination must be carried out only by a qualified medical officer as recognized by the government.  This means that the medical officer should meet all the requirements of 42 CFR 482.55.  Another requirement imposed on the hospital is to display signs within the hospital premises where patients can learn about their rights under EMTALA (Westfall, 2003).

Some clear criteria are set under the Act to determine if a medical condition is an emergency or not.  Although the process of arriving at a conclusion is a medical one based on scientific facts, the criteria under the statute provides a legal framework.  For example, the statute explicates the criteria to determine an emergency condition thus:

“A medical 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 health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, etc… With respect to a pregnant woman who is having contractions – that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or her unborn child.” (Bristol, 2006)

The criteria for “stability” are different for patients suffering from psychiatric illnesses when compared to those brought in for organic traumas.  For psychiatric cases, a patient is declared “Stable for discharge” when he/she is not regarded as a threat to self and others.  Similarly, the emergency physician can declare a patient “Stable for transfer”, when the patient is sufficiently protected from injuries during transfer.  In other words,

“To “stabilize” means to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or . . . with respect to a pregnant women who is having contractions, to deliver (including the placenta).” (Rosenbaum, 2003)

The key words in the provisions for women in active labor are “safe transfer”, “inadequate time” and “threat to health or safety”.  With such clear framing of sentences, the statute leaves no room for ambiguity or misinterpretation.  EMTALA is equally explicit about patient transfers.  The following are the conditions stated by the statute for patient transfer:

1. (For emergency medical conditions) “that no material deterioration of the patient’s condition is likely to result from the transfer or is likely to occur during the transfer”,

2. (For patients in active labor) “the infant and the placenta have been delivered” (Hampers, 2002).

It is important to note that while EMTALA is applicable to the hospitals and the hospital administrators, physicians are also liable for incidents of noncompliance.  Since all private hospitals are also business corporations, the laws applicable to the latter are also applicable to the former.  Some of the clauses in the Act do specifically mention the conduct expected of physicians.  For example, Section 1395dd (d)(1)(C) mentions that penalties could be imposed on the physician who has failed to respond to the emergency situation according to the statute.  Physicians who transfer patients even if the situation does not warrant it can be made accountable for their actions (Hampers, 2002).

Physicians can also be held liable for negligence and incorrect diagnoses.  Physicians are also covered under the State malpractice law for negligence and wrong diagnoses.  Since the scope for the State law is broader than EMTALA, medical personnel who meet EMTALA requirements can still face punitive action under the State malpractice law.  Summers v. Baptist Medical Center of Arkadelphia case is a classic example of punitive action against emergency healthcare personnel for an inadequate process of screening examination.  In this case,

“…an examination of a patient who had fallen from a tree stand while hunting was allegedly incomplete because a chest x-ray had not been included when a set of spinal x-rays was ordered. The physician did not believe that the patient had any fractures, and discharged him home, with instructions. There was no transfer to another facility involved. The patient presented at another hospital two days later, and he was diagnosed with an acute comminuted vertebral fracture, a sternal fracture, and bilateral hemopneumothoraces secondary to untreated rib fractures.” (www.emtala.com, 2003)


While EMTALA is essentially concerned with the hospital receiving the patient first, some obligations are imposed on the hospital that receives the patient through referral.  Usually, patients brought to the emergency ward are transferred only if a more specialized trauma unit is available in a nearby medical facility.  Again, the patient requirements are placed ahead of the hospital’s profitability or its staff’s convenience.  The receiving hospital (after being referred) will inevitably have to provide trauma-care to the patient, except under one condition. Where the primary referring hospital is equally capable of providing treatment to the patient, the referred hospital can refuse to attend to the patient.  If this happens, any deterioration of patient’s health as a result of this futile transfer will be the responsibility of the hospital receiving the patient first.  Exceptions are made for hospitals running at full capacity and not in a position to take any more patients.  Also,

 “If an individual presents to any contiguous or on-campus facility of a hospital that has one or more hospital-owned non-contiguous or off-campus facilities, the emergency medical screening examination must be performed within the contiguous or on-campus facilities of the hospital. In this situation, it would not be appropriate for the hospital to move the patient to an off-campus facility for a medical screening examination. Assuming that coming to the off-campus hospital-based facility is the same as coming to the parent hospital, under the EMTALA requirements, the hospital-based facility must comply with the transfer guidelines.” (www.emtala.com, 2004)

The regulations do no require hospitals to transfer a patient identified to be in an emergency medical condition without the latter’s consent.  The physician needs to certify that there are more benefits attached with the transfer when compared to the potential risks and the hospital receiving the patient is sufficiently equipped and agreed to treat the patient.  The patient’s medical history is made available to the receiving facility and the transfer is carried out only by qualified medical personnel (www.emtala.com, 2003)

Another key provision of EMTALA puts forth the circumstances in which medical personnel, especially physicians in specialty wards, should serve on the hospital’s medical staff on-call lists. The new regulations inform that hospitals will have a right to draw-up their on-call lists by taking into consideration the interests of their communities. The hospitals are no longer required to have doctors on-call at all times.  They can even exempt certain senior medical personnel from on-call duty.  Doctors will now be permitted to be on-call in two or more hospitals simultaneously.

For hospitals and healthcare personnel who breach the obligations under EMTALA, the penalties could be quite severe.  For smaller hospitals, with a total capacity of less than one hundred beds, the pecuniary damages could reach as much as $25000.  For larger hospitals with a bigger intake capacity, the penalty could be twice as much.  EMTALA makes very little distinction between regular and on-call medical personnel.  Even on-call personnel are required to be aware of all their obligations under EMTALA and can attract the same punitive charges as applicable to regular doctors.  If anything, on-call physicians are more prone to violating their obligations.  For example, an on-call physician might fail to respond to his call and arrive at the hospital within the expected time.  He/she is then liable for penalties (Westfall, 2003).

In the final analysis, hospitals with off-campus treatment units should make sure that the emergency department and off-campus medical personnel form effective lines of communication regarding EMTALA related compliance. The hospital should perform in-house training programs to make sure that the medical staff at all its facilities (on or off site) is aware of their obligations as proscribed by EMTALA. Hospitals are also advised to train some of their personnel in emergency lifesaving techniques.  The hospital should also adopt policies and procedures for off-campus, provider-based clinics, urgent care facilities and “fast track” in such a way that the EMTALA requirements are also taken care of.

References:

Bristol, N. (June 15, 2006). EMTALA panel tackles shared call, disaster issues., OB GYN News, 41, 12. p.40(1).

Silverman, J. (May 1, 2005). Hospital midwives seek right to certify false labor: EMTALA’s guidelines leave it up to the hospital to determine whether doctors should examine the patient., OB GYN News, 40, 9. p.40(1

Westfall, P G (March 2003). New rules keep EMTALA in check. Nursing Management, 34, 3., p.24(2).

Hampers, L C, Faries, S. G., & Poole, S R (Dec 2002). Regional after-hours urgent care provided by a tertiary children’s hospital., Pediatrics, 110, 6. p.1117(8).

Rosenbaum, S. (March 26, 2003). The impact of United States law on medicine as a profession., JAMA, The Journal of the American Medical Association, 289, 12. p.1546(11).

Overcrowding crisis in our nation’s emergency departments: is our safety net unraveling?. (Sept 2004)., Pediatrics, 114, 3. p.878(11).

The detailed regulations and statutes from www.emtala.com, retrieved on 10th December, 2007.

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