Understanding EMTALA (The Emergency Medical and Active Labor Act)

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Understanding EMTALA(The Emergency Medical
and Active Labor Act)

• Insert Name of Presenter

Ethics Resource Center American Medical
Association
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Medicines Duty to Provide Charity Care

• Physicians have a professional duty to treat the
  sick, regardless of their ability to pay.
• In its first Code of Ethics (1847), the newly
  founded AMA declared that
• poverty, professional brotherhood, and certain
  public duties . . . should alwaysbe recognized
  as presenting valid claims for gratuitous
  services.

Ethics Resource Center American Medical
Association
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Paying Hospitals for Charity Care

• The earliest US hospitals were poor houses run
  by charities.
• The well-off began to go to hospitals when
  technology provided diagnosis and treatment that
  could not be delivered in the home.
• For much of the 20th century, indigent care was
  subsidized by payment received for treating the
  well-off.

Ethics Resource Center American Medical
Association
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Need for EMTALA

• The rise of health insurance plans, with fixed,
  cost-based reimbursement schedules, made
  cost-shifting difficult.
• ERs began turning away patients who could not
  pay.

Ethics Resource Center American Medical
Association
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The Government Steps In

• Hospitals built under the Hill-Burton Act (1946)
  were obliged to offer emergency treatment to
  those unableto pay.
• EMTALA, enacted in 1986, extended that obligation
  to all hospitals that participate in Medicare
  programs.

Ethics Resource Center American Medical
Association
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EMTALAs Purpose

• To provide an adequate first response to a
  medical crisis for all patients.
• Some translate EMTALAs purpose as to prevent
  hospitals from dumping indigent patients.

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Association
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Requirements of EMTALA

• To comply with EMTALA, a hospital must
• Screen patients to determine whether a medical
  emergency exists,
• Stabilize patients with medical emergencies,
• Restrict transfer of non-stabilized patients to 2
  circumstances.

Ethics Resource Center American Medical
Association
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Definition of Emergency Department

• Originally, the emergency department was defined
  as a specially equipped and staffed area of the
  hospital (that) used a significant portion of the
  time for initial evaluation and treatment of
  outpatients and emergency medical conditions
• More recently, the EMTALA definition of the
  emergency department has expanded.

Ethics Resource Center American Medical
Association
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Expansion of Definition

• On-campus property is based on the 250- yard
  rule
• Off-campus property which includes certain
  provider-based treatment and diagnostic
  facilities, primary care centers, and urgent care
  facilities that are not part of the hospital or
  emergency room complex.

Ethics Resource Center American Medical
Association
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Requirement 1 Medical Screening

• The emergency department must provide a medical
  screening exam to any patient who requests
  treatment (regardless of that patients ability
  to pay) to determine whether a medical emergency
  condition exists.
• The exam should be comparable to an exam offered
  to other patients presenting similar symptoms.

Ethics Resource Center American Medical
Association
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Requirement 1 Medical Screening

• An emergency medical condition is the presence
  of acute symptoms of such severity that the
  absence of immediate medical attention could
  reasonably be expected to result in
• Placing an individuals health in serious
  jeopardy,
• Serious impairment to bodily functions,
• Serious dysfunction of any bodily organ or part.

Ethics Resource Center American Medical
Association
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Requirement 1 Medical Screening

• With respect to a pregnant woman who is having
  contractions, an emergency medical condition is
  one in which
• There is inadequate time for safe transfer to
  another hospital before delivery or
• Transfer may pose a threat to the health or
  safety of the woman or the unborn child.

Ethics Resource Center American Medical
Association
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Requirement 2 Stabilizing Patients with
Emergency Medical Conditions

• If an emergency medical condition exists,
  thehospital must
• Provide treatment until the patient is
  stabilized.
• Then transfer the patient to a medical facility
  that is better able to provide the necessary
  treatment.

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Association
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Requirements of Transferring Hospital

• Provide medical treatment, if possible, to
  minimize the risk of transfer,
• Obtain patients written consent for transfer,
• Provide signed certificate of transfer,
• Assure that the transfer takes place with
  qualified personnel and equipment,
• Send copies of medical records related to the
  emergency condition.

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Association
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Obligations of Receiving Hospital

• Have available space and qualified personnel for
  treating the patient,
• Agree to accept transfer of the patient and to
  provide appropriate medical treatment.
• Regional referral centers and hospitals with
  specialized capabilities cannot refuse to accept
  an appropriate transfer if they have the
  capacity.

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Association
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Requirement 3 Transfer of Non-stabilized
Patients

• Non-stabilized patients may be transferred
• ONLY IF
• The patient (or someone acting on the patients
  behalf) requests a transfer in writing after
  being informed of the risks involved and the
  hospitals duty to treat under EMTALA, or
• A physician certifies that the medical benefits
  expected from transfer outweigh the risks
  involved in the transfer.

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Association
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Liabilities Under EMTALA

• There are 2 courses of action for violations of
  EMTALA
• Private civil suits against the hospital (but
  not the physician).
• HHS penalty fines against hospital, physician,
  or both.

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Association
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Fines Under EMTALA

• HHS may fine and penalize a physician who
• Fails to respond to an emergency while on-call,
• Fails to perform a screening exam,
• Fails to inform emergency patients of the risks
  and benefits of transfer,
• Signs a transfer certification when he or she can
  reasonably be expected to know that the risks
  outweigh the benefits.

Ethics Resource Center American Medical
Association
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Supreme Court Interprets EMTALA Broadly

• One EMTALA case has reached the
• US Supreme Court.
• The Court decided in Roberts v. Galen that a
  hospital may be liable under EMTALA for the
  transfer of a non-stable patient, regardless of
  the motive behind the transfer.

Ethics Resource Center American Medical
Association
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EMTALA and Access to Health Care

• Complying with EMTALA has placed severe financial
  burden on hospitals.
• Burden aggravated by managed care plans that
  limit compensation to in-plan providers.
• Unable to shoulder the financial burden of
  providing uncompensated care, many ERs are
  closing, thus creating greater demands on those
  that remain to care for the indigent.

Ethics Resource Center American Medical
Association
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EMTALA and Quality of Health Care

• Enacted to improve access to emergency care,
  EMTALA is being used to enforce quality of care
  for inpatients and non-emergency outpatients.
• The extension of EMTALA to non-emergency care has
  occurred to fill a void absence of access to
  quality of care by the nations indigent and
  uninsured.

Ethics Resource Center American Medical
Association
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A Bigger, Better Solution Is Needed

• EMTALA is an inadequate bandaid on a national
  malady the lack of access to quality health care
  by the nations indigent and uninsured.
• 42 million Americans are uninsured.

Ethics Resource Center American Medical
Association
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Means for Financing Health Care

• Private (or market) only US system before
  Medicare/Medicaid
• Public (or government) only nationalized or
  other single-payer system such as in Canada,
  United Kingdom
• Private and Public US system today

Ethics Resource Center American Medical
Association
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Proposals for Financing Health Care

• Most current proposals call for a combination
  private-public financing system that would cover
  everyone (universal coverage).
• The AMA proposal, Health Insurance for All
  Americans, is an example of this approach.

Ethics Resource Center American Medical
Association
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Health Insurance for All Americans

• The AMA proposal recommends
• Government-provided tax credits for purchasing
  health insurance
• Recipients use the tax credits to buy insurance
  in the open market
• Those with incomes below taxable levels receive
  government funds with which to buy health
  insurance.

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Association
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Avoid Other EMTALAs

• EMTALA has demonstrated that
• An emergency department act cannot solve the
  problem of access to quality care for all
  Americans.
• Enacting a series of EMTALA-like bandaids (eg,
  NEMTOPS or the Non-emergency Medical Treatment
  for Outpatient Seniors) will not get the job
  done.

Ethics Resource Center American Medical
Association
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Medicines Leadership

• Whatever the solutions to our health care
  problems are, the answers will be better if
  physicians are involved.
• Get involved. Our patients and the public are
  counting on us.

Ethics Resource Center American Medical
Association
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This ethics educational presentation was created
by the Ethics Resource CenterAmerican Medical
Association515 North State StreetChicago, IL
60610Phone [phone]Fax (312)
464-4799Email erc_at_ama-assn.org Web
www.ama-assn.org/go/erc