Effects of EMTALA on Healthcare Essay

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Effects of EMTALA on Healthcare Essay

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

Address prior authorization obligations on delivery of healthcare;
Clarify what is expected of “Dedicated Emergency Departments”
Makes clear the application of EMTALA to inpatient, outpatient, provider based, and other hospital facilities
Re-defines on-call obligations and the responsibility of on-call physicians
Explains its applicability to hospital owned ambulances
And finally, elucidates requirements during national emergencies and other contingencies. Effects of EMTALA on Healthcare Essay.

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.

Some of the essential provisions under EMTALA are as follows: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). Effects of EMTALA on Healthcare Essay.

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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.
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. Effects of EMTALA on Healthcare Essay. 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)

EMTALA: The Emergency Medical Treatment and Active Labor Act The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 as a part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. EMTALA was enacted to prevent hospitals with Emergency Departments from refusing to treat or transferring patients with emergency medical conditions (EMC) due to an inability to pay for their services. This act also applies to satellite locations whom advertise titles such as “Immediate Care” or “Urgent Care,” and all other facilities where one-third of their patient intake are walk-ins. Several rules and regulations to this act have been established and it has become a very serious piece of legislation and health…show more content…
33-41). Patients should be treated with the same medical procedure regardless of their ability to pay or not. On April 7, 1986, President Ronald Reagan signed COBRA into law, which is a part of the Social Security Act. COBRA maintains several rights to patients such as the extension of health care coverage after leaving one’s job (Moy, 2010, pp. 33-41). This ensures the patient will have health insurance even when they are between occupations. Within the 2,000 page legislation is the Medicare and Medicaid amendment section of COBRA where patient dumping, now known as EMTALA, is located (Moy, 2010, pp. 33-41). Effects of EMTALA on Healthcare Essay. Some believed the law was not necessary such as Senator Hatch whom expressed, “I do not support the provisions of [EMTALA] included in this bill. I believe they are premature, over-regulatory, and unnecessarily punitive” (Moy, 2010, pp. 33-41). It is highly important to understand the true purpose of EMTALA, because it can easily be confused with a medical malpractice act or assuring standard of care, but this is not the case. The following excerpt from Moy’s EMTALA Answer Book provides a clear purpose to the establishment of EMTALA: “The avowed purpose of EMTALA is not to guarantee that all patient were properly diagnosed, or even to assure they received adequate care, but instead to provide an ‘adequate first response to a medical

Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA).

Methods

We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements.

Results

Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period. Effects of EMTALA on Healthcare Essay.

Conclusions

EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA’s status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.

Keywords: health policy, Affordable Care Act, emergency medicine, health reform, insurance reform

Since its passage in 1986, the EMTALA has been one of the most comprehensive laws granting nondiscriminatory access to emergency medical care [22], [32]. EMTALA was originally conceived as a policy to prevent “patient dumping”, the refusal of EDs to treat patients who could not pay for treatment [22]. EMTALA mandates that a hospital must appropriately screen, stabilize, and, if necessary, transfer a patient regardless of insurance status or ability to pay. If it is deemed necessary that the patient needs to be transferred, they must be transferred to a facility with appropriate care and the receiving facility must accept the patient [31].

Federal enforcement of EMTALA is managed by two agencies, CMS and OIG. EMTALA investigations are initiated with a complaint being filed with one of the 10 regional CMS offices and typically submitted by patients, hospitals, or ED staff [1]. If a violation is confirmed by CMS field investigators, hospitals must submit a plan to correct deficiencies highlighted by CMS within 90 days [2]. Hospitals that fail to implement acceptable corrective actions risk termination of their Medicare provider agreements, which could result in a significant financial loss and lead to the closure of the facility. If the plan is accepted by CMS, the investigation ends; however, the OIG may still levy punitive fines on hospitals and physicians’ offices. Fines have a maximum of $50,000 per hospital and physician and are not covered by physician malpractice insurance.

Since EMTALA’s implementation, the rate of reported patient dumping has dropped substantially, with recent estimates from 2005–2014 showing rates as low as 1.7 violations for every 1,000,000 ED visits [27]. While these rates represent a sharp departure from previous highs in the 1980s, EMTALA violations suffer from underreporting and hospitals still face compliance issues [12]. Additionally, while EMTALA represents an important safety net for those without insurance coverage, it does not guarantee free care to the patient and is not intended as a substitute for routine care. Under EMTALA, patients cannot be denied emergency care based on inability to pay, but may still be billed after receiving care. This could result in bad debt for both the consumer (i.e., bankruptcy) and the provider (i.e., uncompensated care). EDs already provide more uncompensated care to the uninsured than hospitals or outpatient clinics combined and nationally this amounted to approximately $50 billion in 2013 (HHS.gov 2015).

The insurance expansion provisions of the 2010 ACA lowered the uninsured rate for individuals ages 18–64 years from a high of 18.4% in 2013 to 10.2% in 2016, a reduction of 45% [4]. Effects of EMTALA on Healthcare Essay. While findings of the ACA’s impact on ED utilization are mixed, some recent studies have shown that the ACA is associated with improvements in access to usual sources of care other than the ED and primary care utilization, especially for low-income groups and racial/ethnic minorities [3],[15],[25]. The expansion altered the payer-mix of many providers away from self-pay, which resulted in improved charge capture, reductions in uncompensated care, and potentially served to lower rates of patient dumping [7],[8]. Thus, after the national implementation of the ACA in 2014, we would expect to observe a decline in patient dumping and settlements arising from EMTALA violations. Several proposals to repeal and replace the ACA were estimated by the CBO to reverse nearly all of the gains in coverage attributable to the ACA [5],[6],[13]. Although those proposals ultimately failed to become law during the summer of 2017 legislative session, there are still proposals being circulated to reverse the ACA’s insurance expansion through administrative action and by reducing Medicaid spending via the federal budget.

Hospitals serving large numbers of Medicaid and uninsured individuals are eligible for federal DSH payments, to help offset the costs of uncompensated care. Since the insurance expansion has likely worked to reduce the burden of uncompensated care, the ACA has built-in cuts to DSH payments to help reduce expenditures. These scheduled reductions to DSH payments will place greater strain on safety net hospitals. This increased strain could lead to patient dumping in order to avoid the increased shortfalls in revenue. The impact of DSH payments cuts will be magnified in Medicaid non-expansion states that have many low-income adults in the “coverage gap” [9],[18]. The uninsured low-income population are more likely than their privately insured counterparts to use EDs and impose a risk of uncompensated care for systems [14],[20].

In the face of reform efforts that would increase the number of uninsured patients and the scheduled cuts to DSH payments, it is important to understand the current prevalence of EMTALA violations and their distribution across the country. Despite its importance as a federal law mandating the provision of emergency medicine, little empirical work has been published on EMTALA violations and virtually none has examined the impact of the law within the context of the ACA and current debates about health care and insurance reform [1],[22],[26],[30]. Effects of EMTALA on Healthcare Essay.

This study adds to the current health reform debate by analyzing the content of all settled EMTALA violations from the OIG between 2002–2015 and identifying the prevalence and correlates of these cases. While settled fines do not constitute the universe of violations they are one of the few publically available markers by which to measure EMTALA violations. Additionally, while our findings are not causal in nature, we offer a descriptive analysis of these settlements and discuss the implications of results within the broader context of the current health care reform debate surrounding the ACA.

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2. Methods

This study is a retrospective analysis of settled OIG civil monetary penalty settlements related to EMTALA violations from the OIG. Not every complaint which generates an EMTALA investigation results in a monetary settlement, thus we do not observe the entire universe of EMTALA complaints, only settled violations (approximately 7.9% of all violations [32]). In the event that a violation was found, CMS forwards the case to OIG, where the OIG decides if a monetary fine is warranted. We rely on settled cases as there are few reliable sources of data to assess patient dumping and cases settled by OIG have been used in prior work [30]. For brevity, we hereby refer to settlements that resulted from EMTALA violations as “settlements” in the manuscript.

The OIG website provides a one paragraph description about every EMTALA settlement since 2002. We conducted a content analysis of this information for all 191 settlements posted on the OIG website through 2015. A coding instrument was created in Qualtrics, a web-based survey tool, and each settlement was coded according to the nature of the violation and the characteristics of the patients involved [19]. We coded each settlement according to the year it occurred, the total dollar amount fined, the number of patients involved, and the type of violation that resulted in the settlement (i.e., failure to provide appropriate screening, failure to accept transfer, failure to provide appropriate transfer, failure to provide appropriate stabilization, or unknown). Settlements that occurred but had an unclear cause in the OIG reports were coded as “unknown” in our type of violation measure. Effects of EMTALA on Healthcare Essay.

Hospital financial and geographic data from Thomson Healthcare Profile of US Hospitals were merged with the OIG EMTALA violation data by hospital name and address using Microsoft Excel 2016 [27]. The Thomson data include each hospital’s unique Medicare ID, US Census region (Midwest, Northeast, South, West), geographic status (urban, rural), DSH status, and number of beds.

The merged dataset was imported into R [20] statistical software version 3.4.1 for analyses. First, annual trends in EMTALA settlements were plotted and stratified by type of violation which resulted in a settlement. Second, descriptive statistics were generated to describe hospital and geographic characteristics of violating hospitals. Third, 2010 Census data were used to calculate per-capita average fines at the state-level [30]. Results were plotted on a map of the US to visually explore geographic heterogeneity in EMTALA settlements and fines.

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3. Results

We identified 191 EMTALA settlement agreements, which resulted in settlements that occurred between 2002–2015. A total of 24 hospitals could not be uniquely identified from the settlement reports or had active data in the Thompson database and were excluded from the analyses, for a total of 148 unique hospitals. After merging the settlements with the Thompson data, we had a sample of 167 settlements with associated hospital characteristics, none of which involved individual physicians.

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Figure 1 shows annual trends in settled EMTALA violations from 2002–2015. The Figure is right skewed, which reflects a decline in the overall number of EMTALA settlements that range from a high of 46 in 2002 to a low of 6 in 2015, or a decline of 87%. Settlements did increase by 50% in 2013 relative to 2012, driven mostly by failure to appropriately screen. The shaded bar in Figure 1 indicates the national implementation of the ACA in 2014, which corresponds with a continued decline in overall settlements from 16 in 2014 to 6 in 2015. Effects of EMTALA on Healthcare Essay. Throughout the 2002–2015 study period, the most common reason for a settlement was failure to appropriately screen followed by failure to stabilize.

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Figure 1.

Settled EMTALA Violations by Type, Office of Inspector General 2002–2015. General (OIG) “patient dumping” settled violation case summaries from 2002–2015. These violations reflect settled cases, not all alleged EMTALA violations. The shaded bar represents the national implementation of the Patient Protection and Affordable Care Act.

Table 1 presents descriptive statistics of settled EMTALA settlements, as well as characteristics of violating hospitals. Nearly half of the settlements (47.9%) occurred at hospitals in the South, with the fewest settlements occurring in the Northeast (5.39%). Hospitals in urban areas (74.3%) were more likely than hospitals in rural areas (25.7%) to incur a settlement. Violating hospitals that had a settlement incurred an annual average fine of $31,734, for a total $5,299,500 over the study period. No hospital in the sample had its Medicaid provider agreement terminated as the result of an EMTALA settlement. Information on DSH status was unavailable in the Thomson data for 70 hospitals in the sample. For the hospitals for which their DSH status could be determined, sub analyses were conducted. Over a fifth of the hospitals (22.16%) had DSH status, with 62% of these hospitals located in the South and 65% located in urban areas. Effects of EMTALA on Healthcare Essay.