Introduction

In 1986 the Emergency Medicine Treatment and Active Labor Act (EMTALA) was passed by the United States Congress. EMTALA was part of the Consolidated Omnibus Reconciliation Act (COBRA), which Congress enacted to address Medicare issues. The original intent of EMTALA was to attempt to prevent discrimination of patients in the form of "patient dumping." Patient dumping is a practice of transferring uninsured patients from one hospital to another strictly for financial reasons.[1] This transfer of patients was a practice when private hospitals would transfer uninsured patients to public hospitals without considering their medical condition or if the patient was stable for discharge.[1] This situation occurred in most large cities, such as Chicago or Dallas, where public hospitals were receiving an increasing number of transfers strictly for financial reasons.[1] Several reports by both medical professionals and the lay press described the problem of patient dumping at the time. The growing attention from these reports, as well as the increasing presence of the federal government in health-care delivery, led to the development of EMTALA.[1]

Issues of Concern

MTALA applies only to hospitals that accept payment from The Department of Health and Human Services (HHS), Centers of Medicare and Medicaid Services (CMS) under the Medicare program.[2] However, this is nearly 98% of all Unites States hospitals.[1] Three legal responsibilities are required of participating hospitals by EMTALA.

The first of the three legal requirements enacted by EMTALA is that the hospital must provide a medical screening examination (MSE). A medical screening examination must be performed on any person who presents to the hospital and is requesting treatment to determine if an emergency medical condition (EMC) exists (BUMC). EMTALA defines an emergency medical condition as:

"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the individual's health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment to bodily functions; or serious dysfunction of any bodily organ or part; or (2) concerning a pregnant woman who is having contractions, that there is adequate 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 the unborn child".[3]

The hospital's emergency department completes the screening examination requirement by not altering its normal, standardized screening procedure.[2] This MSE cannot be delayed by obtaining information regarding the patient's ability to pay or insurance status. All patients presenting to the emergency department with a potential emergency medical condition are covered under EMTALA; this does not apply solely to Medicare patients. As a result, a medical screening examination should be performed and documented on every patient presenting to the emergency department for medical care.[1] This rule does not just apply to the physical space of the emergency department but the hospital's property. It is inclusive of the hospital campus, such as clinics and departments within 250 yards.[1] Ambulances which are hospital-owned and operated are also subject to EMTALA. Regarding the medical screening examination, there are no legal requirements as to who exactly performs the MSE; it should be "qualified medical personnel." It also does not describe what specifically constitutes the exam. On-call specialists may be needed to assist with the MSE or to help stabilize a patient. Under EMTALA, hospitals must have an on-call list that is representative of typical services provided at that hospital and maintain that list for five years.[1]

The second legal requirement of EMTALA is regarding patient stabilization and treatment. If the patient has been found to have an emergency medical condition, they must stabilize the patient. The hospital can alternatively transfer the patient to another hospital. A hospital cannot transfer an unstable patient unless the patient requests a transfer, and a physician certifies that the benefits outweigh the risks of the transfer of an unstable patient.[2] The transfer of the patient must follow detailed guidelines set by EMTALA. An appropriate transfer, as stated by Smith in "EMTALA Basics: What Medical Professionals Need to Know," is defined as:

1. The transferring hospital provides medical treatment to minimize risks to the individual's health or the unborn child's health.
2. The receiving hospital has space available, has qualified personnel to treat the individual, and has agreed to accept the individual and provide treatment.
3. The transferring hospital sends to the receiving facility all available documents related to the emergency condition.
4. The transfer takes place through the use of qualified personnel and appropriate transportation equipment.
5. The transfer meets any other CMS requirements necessary in the interest of the individuals transferred.[2]

The final legal requirement of hospitals with specialized services, such as a burn-unit, must accept patients with the need for those specialized services; this is to prevent accepting specialized hospitals from refusing transfers based on their ability to pay or insurance status. When another emergency department contacts a hospital with specialized services, they can ask no questions regarding insurance.[1] If a facility has the capacity, i.e., available beds and the ability to care for the patient, they cannot refuse transfer.

Clinical Significance

EMTALA enforcement is through the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General of the Department of Health and Human Services. If a violation is reported, the regional CMS assigns the investigation to a state-level.[3] Physicians and hospitals that violate EMTALA can be liable for a fine of $50,000, which is not covered by malpractice insurance.[4] There is also the possibility of losing Medicare and Medicaid funding for repeated or blatant violations.[3] A study by Zuabi et al. looked at EMTALA investigations by the Office of the Inspector General of the Department of the Health and Human Services from 2002 through 2015; there were a total of 192 settlements. The fines totaled were $6,357,000. Most of the EMTALA violations were for a failure to provide a medical screening examination and, secondly, failure to stabilize patients found to have an emergency medical condition. The same study found that the average fine against hospitals was $33,435 and $25,625 against individual physicians. Hospitals received the majority of the penalties and were responsible for 95% of the cases.[3]

Hospitals and physicians need to be familiar with the details of EMTALA to avoid potential violations and to continue to ensure all patients receive equal and appropriate emergency services. Significant health care funding cuts from both the private and public sectors continue to put pressure on emergency care and, subsequently, EMTALA's safety net providers. Access to emergency care for the uninsured and underinsured was the driving force for the enactment of EMTALA in 1986 and continues to remain just as important today.