Financial Repercussions of Enforcing the EMTALA

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Table of Contents

Importance of the Topic
EMTALA and Its Essence
Patient Dumping
Challenges Caused by EMTALA
Increased Liability Exposure
Inadequate Medicaid Reimbursement
Limitations of the Study
Conclusion
References

Importance of the Topic

Nowadays, considerable progress can be observed in the sphere of medicine. The work of hospitals and the conditions under which people may receive the required medical care has been improved. At the same time, certain limitations and unpredictable outcomes take place. Not all people become able to get the required portion of treatment in time. The way how patients are diagnosed can vary a lot. That is why there is a necessity to consider a list of standards according to which people may understand their rights and opportunities regarding the sphere of medicine.

The Emergency Medical Treatment and Labor Act (EMTALA) is one of the attempts to define the level of quality of the services offered in hospitals. EMTALA is a well-known federal law under which anyone is provided with an opportunity to come to a hospital and be treated without considering the person’s insurance and financial status. It was developed in 1986. Since 2000, a number of changes have taken place and led to certain financial repercussions of enforcing EMTALA (Simonet, 2009).

The changes touched upon such aspects as increased liability exposure (O’Shea, 2007), inadequate Medicaid reimbursement (Hamel, Ruger, Ruger, & Annas, 2015), and patients’ dumping (Price, 2011; Rosenbaum & Kamoie, 2003). People need to know their rights and understand that their health is a priority that cannot be neglected. The crisis that takes place in emergency departments today is a hot issue, and the affordable care act has to be a guarantee for patients to rely on but not a curtain with a number of financial uncertainties left behind.

EMTALA and Its Essence

The current literature review is the possibility to understand how different financial repercussions that are connected with enforcing EMTALA can influence patients’ treatment and the conditions that are created for people to improve their health. Progress in the sphere of medicine is observed in a variety of countries around the whole world. In the United States, this progress has been observed since the 1980s (Simonet, 2009). However, a number of unclear ethical and financial issues bothered millions of people. To find an appropriate and reasonable solution for such misunderstandings, the enactment of EMTALA was supported. Under this law, all federally funded hospitals were obliged to provide patients with the required portion of non-discriminatory care to stabilize a person, reduce the patient’s suffering, and make it possible to transfer a patient to another department (Rosenbaum & Kamoie, 2003). However, the appearance of EMTALA did not change the situation.

Even though the law was created to protect the rights of low-income patients, who required emergent medical services, the main problem was not solved (O’Shea, 2007). The essence of EMTALA was poorly understood by many hospitals and governments and remained to be an unfunded mandate. O’Shea (2007) admits that the law that aimed at helping patients turned out to be the main and impenetrable barrier for patients to get the required emergency medical care within a short period of time. Rosenbaum and Kamoie (2003) also underline the controversial nature of the statute because of the absence of definite studies on the costs that could be attributable to EMTALA and explain liability considerations and financial outcomes in a clear way.

Patient Dumping

Many American hospitals established charity care as a possibility to improve their financial positions. Within a short period of time, some hospitals gained independence and managed all activities and services offered. However, some hospitals became dependent on the level of fees offered by patients. A serious competition took place between the hospitals that wanted to have as many paying patients as possible. It became impossible for many people to have medical treatment without paying for it. Nonprofit hospitals did not want to treat people for free (O’Shea, 2007). They set prices, and many patients could not pay for their treatment.

One of the main reasons why EMTALA was supported by all American states was the possibility to discuss the aspects of “patient dumping” many people had suffered from till the middle of the 1980s. For a long period of time, patient dumping was a problem people faced with. In the middle of the 1980s, more than 200,000 patients in the USA was refused treatment at private hospitals annually because of their inabilities to pay for medical services, low incomes, or other grounds that could be hardly related to the patients’ needs mentioned by hospitals (Price, 2011; Rosenbaum & Kamoie, 2003). That practice was justified in private hospitals. There was no particular law that could protect the rights of patients. That was why private hospitals could easily refuse a patient in providing services if he/she could not pay for them.

Patient dumping was the reason for many people to suffer from the inabilities to get the required treatment in time. Research conducted by Price (2011) explained patient dumping in terms of the necessity to provide pregnant women with appropriate medical services. It happened once that a pregnant woman addressed the nearest private hospital because of the unbelievable pain she had. One hospital did not even examine the woman because she did not have insurance. Another hospital accepted the woman, and the doctor provided her with a diagnosis but not treatment. The woman tried to reach the available public hospital. By the time she did it, the baby had died. It was one of the most terrible and unacceptable examples of patient dumping. It proved that there was a burning necessity to promote changes and help people protect their lives and the lives of their born and unborn children. On the one hand, from a legal point of view, private hospitals did not break the law and followed the standards set by the state. On the other hand, from a purely human point of view, their inability to help the woman caused the death of a baby. With the inability to gain control over the decisions made by private hospitals, it was crucial to change the situation and provide people regardless of their social status and financial challenges with the opportunities to receive emergency medical services.

Challenges Caused by EMTALA

Enforcing EMTALA was a chance to help people. However, that kind of enforcement led to certain financial repercussions. Under the Hill-Burton Hospital Survey and Construction Act of 1946, hospitals could receive funds from the government to modernize medical services (O’Shea, 2007). Though hospitals used the possibilities of such internal subsidization, it was not enough to cover all costs and benefit from providing services. After the DRG (diagnosis-related group) payment system had been offered, hospitals got a chance to avoid treating non-paying patients. It caused millions of misunderstandings and complaints. EMTALA was the response. It made all hospitals, public and private, provide the required portion of treatment to stabilize the condition of a patient before transferring him/her to another hospital or department (Price, 2011). Though the main purpose of the law was to protect patients and identify their rights, it led to an increased number of uninsured patients and considerable financial pressure on hospitals. Enforcing EMTALA and the inability to give clear explanations of such terms like “emergency condition” caused certain problems. Hospitals did not receive the necessary compensations for the services offered (Simonet, 2009). Hospital representatives and investors were not satisfied with the conditions under which services were offered. EMTALA made it possible for all people including uninsured patients and immigrants to receive medical services (Hamel et al., 2015). People were able to address the ER even if they required non-emergency care (Fontenot, 2014). Such opportunities became real damage for many hospitals. It was necessary to clarify many aspects. A new stage of enforcement took place. The results of enforcing EMTALA were mixed: on the one hand, it helped hospitals to control and evaluate the conditions of patients, who required help; on the other hand, many patients became unavailable to get medical help again.

Enforcing EMTALA required many stages to be passed and more financial costs to be spent. First, the complaints of the patients, who did not get emergency medical care, had to be investigated by the State survey agency or directly by HCFA Regional Office. Then, it was necessary to understand if the complaint was justified and had enough reasons to be developed further or not. As soon as the complaint was authorized, it was necessary to consider the possibility of the judgment of liability of a hospital or its particular worker. Such a long and thorough way to investigate cases required a number of financial costs to be spent. Many people had to be involved. Due to the possibility to describe the relations between a hospital and a patient in a written form, many hospital representatives did not want to be involved in additional investigations and try to meet patients’ expectations or rely on the law to protect their rights and define their obligations (O’Shea, 2007).

Increased Liability Exposure

At the same time, such enforcement of EMTALA influenced the way how a hospital liability could be exposed and increased. O’Shea (2007) identified increased liability exposure as a burdensome problem for many physicians and the possibility to explain why so many specialists did not want to provide patients with ED coverage. O’Shea’s work (2007) was developed from the studies conducted by the American College of Surgeons/Congress of Neurological Surgeons. It was proved that more than one-third of all revealed medical cases came from the patients, who had been diagnosed or rejected to be diagnosed in the ED. Doctors admit that the fear of liability turned out to be the main reason for why the quality of medical care had worsened.

At the same time, it seems to be strange that the quality of care is inversely proportional to the idea of liability. In O’Shea’s research (2007), it was stated that specialists were not satisfied with the idea of increased liability exposure because it was unfair to remain the liability risk uncompensated in regards to the care offered. Medical malpractice was not defined as a federal issue. It was more a state issue, and EMTALA did not intend to substitute that issue. However, it was considered as a federal instrument with the help of which even uninsured patients got access to medical treatment at the ERs the same way insured patients did. In other words, EMTALA focused on the comparability of services than on competency, and hospitals were not obliged to reach the correct diagnoses but just to give any diagnosis to all people (Rosenbaum & Kamoie, 2003).

Inadequate Medicaid Reimbursement

One more important aspect of EMTALA is its attempt to control and understand the peculiarities of Medicaid work and its impact on human lives. Medicaid is a well-known health care delivery program available to all US citizens including the indigent. The representatives of Medicaid admitted that EMTALA could measure the possibilities of hospitals, that was why a number of clarifications and explanations should be given. For example, to avoid any possible uncertainties in regards to Medicaid reimbursements, its representatives identified the concept of a “dedicated emergency department” and underlined the necessity of written policies to be clarified to patients (O’Shea, 2007). Hamel et al. (2015) informed that Medicaid varied from state to state, and it was hard to define general standards that should be followed. Each state had its own payment levels including or excluding nursing care at home. With the help of EMTALA, Medicaid was introduced as a federally funded health care program and managed by states accordingly. Medicaid patients became more steered to free options in public hospitals in non-emergency cases with the same quality as they address the ER (Fontenot, 2014).

Such conditions and the inabilities to earn made hospitals undergo considerable economic pressure. It was caused by the decline in reimbursement. The existed financial instability led to inadequate Medicaid reimbursement as well and the reduction of payments made by private insurers (O’Shea, 2007). Hospitals needed more improvements and restructuring with the help of which that could be able to respond to the financial problems. The EDs were overcrowded. Many people wanted to use their opportunities to have free medical treatment and make sure their conditions were stabilized. Medical workers noticed that the presence of many patients in the department at the same time decreased the quality of care offered. Medical workers were bothered with the necessity to take responsibility for any kind of risk due to possible medical malpractice. Patients were eager to be treated in a short period of time. A number of misunderstandings took place at urban and teaching hospitals. Low-income patients and ordinary people, who wanted to check their conditions, got access to use the services of the EDs. Even the fact that they did not have insurance did not prevent them from getting help. Besides, it was stated that people with insurance and abilities to be properly treated were more likely to address the EDs in comparison to other groups of people (poor, uninsured, pregnant, etc.) (O’Shea, 2007). It was hard to understand why people, who could allow medical treatment any time they want, use the possibilities of other people to do the same.

Limitations of the Study

The main limitation of the topic under consideration is that even if EMTALA was used to promote positive health care rights, a number of Americans remained to be unprotected and vulnerable in regards to the existing laws and opportunities (Hamel et al., 2015). It means that even if people are under the protection of the government, they can be under threat of malpractice, too high payments, or delayed services. The limitations that are able under the law lead to the limitations of the study under consideration. As soon as EMTALA was introduced to society and limited the conditions under which medical workers offered their services and patients required for medical help, the limitations of financial outcomes and the impossibility to help patients took place. People knew that they could ask for help and not pay money. In their turn, medical workers know that they can still refuse the necessity to provide patients with care. As soon as patients addressed the courts to prove their rights and blame hospitals for malpractice, hospitals demonstrate the presence of a number of bills indicating uncompensated care (Price, 2011). It happens because of the level of background knowledge of patients and medical workers. A patient does not know enough about the quality of care available to him/her. Layers cannot realize the whole essence of medical treatment. A doctor or any medical worker has been trained and educated to understand what type of medical care can be offered in a particular situation (Price, 2011). The US court system cannot be defined as perfect. That is why not all patients are ready to prove their rights, and hospitals have all possibilities to use the law and defend their decisions. At the same time, patients cannot be sure what is more beneficial for them: to let lawyers and judges investigate their rights and protect their medical care opportunities or to let professional doctors explain an actual state of affairs and explain what kind of care is available for them (Price, 2011). This dilemma cannot be solved even with EMTALA.

Conclusion

In general, this literature review of the financial repercussions of enforcing EMTALA helps to realize that the issue of available medical care remains to be open even after several adjustments and changes have been offered. Though EMTALA is the federal law that helps all people, regardless of their social status and the level of income, get medical care at an Emergency Department, patients continue facing some problems and challenges. Uncompensated care turns out to be a burning problem for many hospitals. Medical workers cannot provide the required guarantees in regards to the quality of services they have to offer. There are certain conditions under which patients can ask for a free examination and suggestions offered by the experts.

EMTALA underlines the obligations every hospital has to complete. However, not all patients know how to use their rights or when it is necessary to sign papers, or it is better to avoid signing at all. The emergency departments aim at providing patients with primary care that can help to stabilize their conditions of patients. Any kind of help has its cost. However, people believe that all services are free to them. As a result, financial misunderstandings and repercussions take place. The investigations by Fontenot (2014), O’Shea (2007), Simonet (2009), Price (2011), Hamel et al. (2015), and Rosenbaum and Kamoie (2003) helps to clarify the conditions under which EMTALA can help patients and define the quality of services offered by hospitals. This literature review explains that the American government tries to take care of its citizens in a variety of ways. Still, the Americans, as well as other representatives of different nations, are not always able to use the possibilities available to them properly and benefit from all services.

References

Fontenot, S.F. (2014). Affordable care act: Lifting the curtain on health care costs. Physician Executive Journal, 40(2), 78-83.

Hamel, M.B., Ruger, J.P., Ruger, T.W., & Annas, G.J. (2015). The elusive right to health care under US law. New England Journal of Medicine, 372(26), 2558-2563.

O’Shea, J.S. (2007). The crisis in hospital emergency departments: Overcoming the burden of federal regulation. Backgrounder, 2050, 1-11.

Price, R. (2011). Killer mandate: EMTALA and its financial effects on hospitals and immigrants. UMKC Law Review, 80(3), 881-903.

Rosenbaum, S. & Kamoie, B. (2003). Finding a way through the hospital door: The role of EMTALA in public health emergencies. Journal of Law, Medicine & Ethics, 31, 590-601.

Simonet, D. (2009). Cost reduction strategies for emergency services: Insurance role, practice changes, and patient accountability. Health Care Analysis, 17(1), 1-19.

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