The Emergency Treatment and Active Labor Act (EMTALA)

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Introduction: The Emergency Treatment and Active Labor Act (EMTALA) aimed to target such patients who were being refused for emergency medical treatment due to their insufficiency for payment of medical and hospital bills. Initially, EMTALA tried to look into such issues where some hospitals were either transferring or discharging and most of that they were denying patients for the treatment since they did not possess any insurance policy.

In 1986 EMTALA was put under law in association with Consolidated Omnibus Budget Reconciliation Act (COBRA) (Schecter, Para 1).In 2003 the Centers for Medicare and Medicaid (CMS) revised EMTALA that is included on September 9, 2003 in the Federal Register (Schecter, Para 1).

There are two main prerequisites by EMTALA (Schecter, Para 2)

Any patient, who approaches the hospital emergency department, must be provided with a suitable medical screening examination by the hospital to check if the patient needs emergency medical treatment (Schecter, Para 2).
Schecter mentions If the medical screening examination shows the patient’s emergency medical condition, it is the responsibility of the hospital to stabilize medical condition before they transfer or discharge the patient (Schecter, Para 2).

EMTALA is controlled by the CMS that is the part of the Department of Health and Human Services (HHS) (Schecter, Para 4). If EMTALA rules are violated, there could be remarkable financial consequences. Whoever is responsible for violating rules of EMTALA, whether a hospital or a physician, could be fined by the government. In addition to that the hospitals are not allowed to participate in any Medicare program that can cause the hospitals a financial damage. It is must for such physicians to know about EMTALA regulations and must work under those directives.

EMTALA Statute: 42 USC 1395 dd42 USC 1395 dd: It refers to examination and treatment for emergency medical conditions and women in labor. It is also known as Section 1867 of the Social Security Act and Section 9121 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Emergency Medical Treatment and Active Labor Act, Para 1).

Early Ambiguity: The text of the EMTALA statute does not clarify some specific key terms like ‘comes to the emergency department’. It also does not say much about EMTALA’s relationship with the patients as the patients moved out through hospitals only in case of transfer or stabilization (The Application of the Emergency Medical treatment and Labor Act (EMTALA) to Hospital Inpatients, Para 9).

Some courts take the meaning of the term ‘come to the emergency department’ as EMTALA would not be applicable for hospital inpatients, on the other hand admitted who developed emergency conditions during their hospital stay (The Application of the Emergency Medical treatment and Labor Act (EMTALA) to Hospital Inpatients, Para 11).

Background of EMTALA Regulations: Sections 1866 (a) (1) (1), 1866 (a) (1) (N) and 1867 of the Act consist of some particular obligations on some specific Medicare-participating hospitals and CAHSs (Proposed EMTALA Regulations: Background, Para 1).These obligations favor all the persons who visit the hospital’s emergency department and are willing to take examination for a medical condition. It is applied to all the people, not considering whether they are beneficiaries of any program under the Act or not (Proposed EMTALA Regulations: Background, Para 1).

Section 1866 (a) (1) (1) (i) of the Act includes if hospitals are not able to fulfill EMTALA obligations, their Medical provider agreement will be terminated. That will put a financial damage for them making a loss of all Medicare and Medicaid payments (Proposed EMTALA Regulations: Background, Para 2).Section 1867 of the Act includes medical screening examinations for the people who visit the hospital for examination for a medical condition (Proposed EMTALA Regulations: Background, Para 3). If the hospital discovers that a person needs an emergency medical condition, then the person must be given stabilizing treatment or a suitable transfer to other medical faculty where stabilization can be performed (Proposed EMTALA Regulations: Background, Para 3).

Section 1867 of the Act includes the obligation of the hospitals where they are supposed to take suitable transfer from other hospitals (Proposed EMTALA Regulations: Background, Para 4). This section focuses on giving the people special facilities which they must get in a participating hospital which has such special facilities like burn units, neonatal intensive care units, and shock trauma units etc. They should not be denied by the hospital for this transfer from one hospital to other to get such special facilities in the case where the hospital is able to treat the people (Proposed EMTALA Regulations: Background, Para 4).

EMTALA Obligations: EMTALA has some particular obligations for all the concerning bodies like participating hospitals, the treating and transferring physicians and the receiving physician and hospitals.

Following are the main points (Schecter, Para 5)

Medical screening exam

Scheter mentions that any patient must get a medical screening exam (MSE) who is going through emergency services. MSE checks whether an emergency medical condition EMC is present or not (Schecter, Para 5).
MSE can be requested by any one of these, the patient himself, someone with the patient, a law enforcement officer with a patient who is brought to ED or someone going into ED for a blood pressure check ups (Schecter, Para 5).
If medical screening exam shows an emergency medical condition, it becomes the duty of the treating hospital to make patient stable before discharging or transferring him (Schecter, Para 5).

Coverage of ‘250-yard rule’ (Schecter, Para 6)

EMTALA rules are not only for the people who visit hospitals for the ED requesting treatment but also for those individuals who are present on the hospital campus and need emergency services.

The hospital campus’s 250 yard rule can be defined as follows (Schecter, Para 6):

Campus is that area which is near to the provider’s main building that is located in 250 yards of the main building (Schecter, Para 6).
Schecter mentions that the ‘250-yard rule’ call for hospital staff to check if a visitor, employee or anyone in the hospital campus requires medical screening examination (Schecter, Para 6).
The campus consists of sidewalks, parking lots, driveways and inpatient and outpatient areas (Schecter, Para 6).

Patient Transfer

The physician who is in charge of treating the patient can transfer him in the following situations (Schecter, Para 7):

While transferring, the physician who is treating the patient must put the name of the person and the facility on the document. He should send related documents, and imaging studies to the emergency department (Schecter, Para 7).
The receiving hospitals must agree to the transfer till they have capacity and space for that (Schecter, Para 7).
It is an obligation for the transferring hospital to provide with all medical treatment according to its capacity which will be very helpful in covering the risk for a person’s health. At the time of transfer the skilled personnel should be with the patient keeping all the suitable medical equipments (Schecter, Para 7).

On call physician duty

The hospitals should have on call list of physicians that should fulfill the needs of the patients fully. The hospital should make a plan according to situation when on call specialist is not present (Schecter, Para 8).
On call physicians may work in many hospitals at a time so they can schedule voluntary processes during on call hours (Schecter, Para 8).
Such physicians are needed to respond immediately to support in the stabilization of the patient with an emergency medical condition (Schecter, Para 8).

EMTALA obligations are achieved when

A suitable MSE recognizes there is no emergency in medical condition (Schecter, Para 9).
When the patient does not give his approval to the treatment which is offered to him or he does not give approval to transfer offered (Schecter, Para 9).
The emergency medical condition becomes stable (Schecter, Para 9).
Schecter says that EMTALA obligations are not for those patients who are present for nonemergency services; he needs an emergency medical condition after they are treated as outpatient (Schecter, Para 9).

Enforcement

CMS puts into effect EMTALA legislation. EMTALA rules are applied on a hundred bed hospital that can be fined up to $50,000 according to violation and the hospital having less than hundred beds could be fined up to $25000 according to violation (Schecter, Para 10).Schecter states that a physiciansas well as on call physician may also be fined in case of absence and negligence (Schecter, Para 10).

Patients enclosed with EMTALA

EMTALA regulations are for all those hospitals whoever involves itself in the federal Medicare program. These regulations are applied on all patients as well. Federal and military hospitals put up with EMTALA regulations though they are not benefitted with medicare program. EMTALA rules are for all those individuals who come to the emergency department and are covered by the ‘250 yard rule’.

According to EMTALA, an emergency department can be classified as follows (Schecter, Para 10):

The state has given such department a license as an emergency department (Schecter, Para 10).
Apprehended by the people as an emergency department or urgent care center (Schecter, Para 10).
That has been available at least for one third visits in an emergency that is without a prior appointment in the previous year (Schecter, Para 10).

Suppose a patient is inside an ambulance, if it is needed the ambulance can be diverted from its rute and it will not violate the rules of EMTALA because the patient has not come actually to the Emergency Department (Schecter, Para 11). If the ambulance that is being used for this purpose belongs to the hospital, can be understood as being used as part of the community EMS system then in this case the patients are not covered by EMTALA on condition that the ambulance is being directed by EMS not the hospital to which it belongs to (Schecter, Para 11).

Medical Screening Examination

The physicians’ responsibilities under EMTALA could be confused by the term of medical screening examination (MSE) which are not as same as their evaluation. Medical Screening Examination can be defined as ‘an assessment that is calculated to recognize emergency medical conditions on the basis of signs and symptoms’ (Schecter, Para 12). The definition includes the requirement of any diagnostic aids or special consultation that is present in the emergency department. Like, a patient coming to emergency department may have any severe health problem like chest pain etc. and he may need an ECG or something for check up his chest, which could be the condition of medical screening examination.

A well qualified QMP should do medical screening test. Though EMTALA regulations do not stop a nurse from performing medical screening examination still it is preferred that a physician performs this task. If a nurse or mid level provider go ahead with this task of medical screening examination, the qualified medical provider should know about the task properly. His qualifications and capacities should be set up and those individuals are approved for this job, their designation should be mentioned on their staff file.

Emergency Medical Condition

Emergency medical condition can be defined as follows:

“A medical condition marking itself as a serious symptom where the negligence of proper treatment can result in putting the health of the individual in a risk like serious injury to any body part or serious dysfunction to any part of the body” (Schecter, Para 14).

After analyzing an unknown emergency medical condition, it is not so that the hospitals or the physicians voilate the EMTALA regulation, since the evaluation is already done by them. If a physician diagnoses that the patient’s condition is critical he must provide a proper treatment of his critical physical condition. In emergency medical condition the patients must get medical screening examination to recognize their medical problems which are responsible to their psychiatric condition Stabilization.

Stabilization is generally the treatment of the emergency medical condition to make sure that there will not be any harm to the patient after transfer or discharge from the hospital. If a patient’s condition gets worse just after the transfer or discharge from the emergency department of the hospital, EMTALA rules are not violated in such situation, Instead, the body of the patient is the prove of his emergency medical condition to determine his stabilization by the physician.

But sorry to say, there is not any clear formula in legal as well as medical profession, which can tell about a patient’s stable condition. If we take an example, an emergency physician will not allow transferring a patient who is diagnosed with a crucial disease and still stable and his vital signs are normal and he is not going to have any further problem. EMTALA legislation supports cautious measures before a patient is transferred or discharged by the physician or the hospital.

The need of EMTALA is to convey that the patient should be stabilized according to the hospitals’ capabilities. It is pertinent to the case where an adult visits a pediatric hospital and develops an emergency medical condition (Schecter, Para 19). In this situation, the responsibility of pediatric emergency department staff is to try to stabilize the condition of that adult patient by using their best resources and they should be dependent on EMS or wait for their vising the place. So basically EMTALA rules focus on giving stabilzation to the patient in need of emergency care which would be according to the hospital’s capacities.

Transfers

After stabilizing the medical condition of a patient, he could be transferred to the other hospital where he can get better medical services according to his medical condition. There are some conditions in which a patient whose emergency medical condition is not stabilized still could be transferred devoid of failing to follow the regulations of EMTALA (Schecter, Para 20). Following are such situations:

The patient himself writes an application for transfer after understanding the risks and benefits of the transfer though he is told about the hospitals’ EMTALA regulations for the treatment (Schecter, Para 20).
The physician in charge for the treatment confirms that benefits of the transfer are more important than the risks (Schecter, Para 20).
The on call physician is not available at that required time and it is established if his services are not available then transfer is more beneficial than taking any other risk (Schecter, Para 20).

Women in Labor

EMTALA refers to the ‘Emergency Medical Treatment and Labor Act.’ EMTALA’s rules are same for emergency medical patients as well as women in labor. Following are the definitions that could be applied to women in labor (Schecter, Para 22):

The condition of all women in labor is understood unstable so they are required to have an emergency medical condition (Schecter, Para 22).
Stabilization could be achieved if (Schecter, Para 22)

The physician announces the labor to be false

Labor ceases

The infant and placenta are delivered:

The rules for transfer for women in labor are as same as emergency medical patients. A woman in labor who has not been stabilized as her infant or placenta are delivered could be transferred if the benefits of transfer are understood more important than the risks taken (Schecter, Para 22).

Special Situations of EMTALA

EMTALA waivers

Schecter says that specific situations like severe storms and all are not considered as the disobedience of EMTALA rules. They can be waived off in those certain situations (Schecter, Para 23).

An emergency department working under EMTALA waiver can be saved from harm against sanctions coming from the negligence of medical screening examination or transferring the patient whose emergency medical condition is not stabilized (Schecter, Para 24). On the other hand, emergency department does not treat the patient or transfer the patient since he is not able to pay, they will definitely receive sanctions despite of their temporary waiver (Schecter, Para 23). Schecter states that there are some examples of disasters when EMTALA waivers happened like, New Orleans (2005), Hurricane Katrina, Hurricane Dean, Texas (2007), Indiana and lowa Storms (2008) (Schecter, Para 23).

Blood alcohol testing

Schecter states that law officers themselves take initiatives and can bring patients to the emergency department to test alcohol in their blood (Schecter, Para 24).It is not the case of the need of a medical screening examination but if the patient himself requests for a medical screening examination or the staff understands the requirement of a suitable medical screening test, EMTALA obligations should be fulfilled (Schecter, Para 24).

Sexual assault nurse examiner cases

A number of emergency departments appoint sexual assault nurse examiners to check injuries and collect forensic report for such patients who face sexual harassment. Such cases also come under EMTALA and sexual assault nurse examiners should suggest the patient a medical screening examination (Schecter, Para 25).

Changes in the healthcare environment

A great number of patients is increasing to visit the emergency departments. During 1994 to 1998, it increased from 90.5 million to 94.8 million (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 13).This growth was not same state by state. The growth was 2 percent in Arizona and whereas it was 12 percent in California (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 13). It was found that uninsured people were facing more difficulty in getting healthcare than getting more access to health care (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 6).

Reviewing some EMTALA cases

The US District court for the District of Puerto Rico denied dismissing a case that was filed by the survivors of Alfonso Domenech (Frew, Para1). Frew mentions that Alfonso was discharged from the hospital though he complained about his chest pain and also his abnormal test results. The hospital rejected the violation charges of EMTALA by giving explanation that it had provided an emergency medical screening examination and consulted with an internist (Frew, Para1).

The court ordered that there was a fact present to prove that the hospital followed all the procedures for the medical screening examination (Frew, Para2). The court also ordered that the applicant’s allegation against hospital’s failure of stabilization would be investigated (Frew, Para 2).

In another case, in an incident a 41 year old paraplegic man was crawling on the road when a hospital contracted van dropped him there (Frew, Para 1).The hospital officers were not ready to accept this blame. They denied the request of City Aorney’s Office for the patient’s medical records but hospital showed its concern by not disclosing the patient’s privacy. City officers found it a case of EMTALA violation where a medically unstable person was released or transferred (Frew, Para 2).

EMTALA and the Swine Flu

Swine Flu (H1N1 influenza) has been a much talked issue recently. The businesses are making themselves ready to face its impact especially at workplace (Jourdain, Para 1). Jourdain further mentions that the health care providers are getting ready to experience an increase in demand for their services. In emergency cases it is really challenging to provide special room care according to the Emergency Medical Treatment and Labor Act (EMTALA). The hospitals have to balance the orders of EMTALA with demand for their services. Jourdain states that luckily, the Department of Health and Human Services through the Centers for Medicare and Medicaid Services (CMS) presented a fact sheet in which it is mentioned how to obtain EMTALA waivers and also it says about options for managing the demand for health care services (Jourdain, Para 1). It is the responsibility of the providers of the emergency health care services to work under EMTALA regulations and ask for guidance under some specific situations. It is all mentioned in that fact sheet (Jourdain, Para 1).

Impact of EMTALA

The implementation of EMTALA has been very beneficial according to the hospitals and physicians. It has not only given access to the patient to emergency medical services but also it has lessened the chances of patients’ throwing out the hospitals. Still, it is very difficult to evaluate the complete success of EMTALA and to measure its effects. Most of the hospitals have reported that implementation of EMTALA has affected very badly the efficiency of the physicians as well as hospitals. It has also affected severly the type of services of the hospital emergency department.

EMTALA regulations increase extra costs to the hospitals and physicians (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 3). Like, EMTALA has encouraged many people visiting to the emergency department that overcrowd the place and does unnecessary delays in the services. The growth of uninsured population visiting emergency department is creating problem in evaluation of individuals. Also, there are less physicians who are joining hospital staff and involving themselves in emergency department on call panels because EMTALA is not supportive in giving such on call physicians any remuneration (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 3).

Some hospitals and physicians are not sure about their responsibilities under EMTALA. They do not know the difference between a medical screening exam and a general exam. They are confused how EMTALA is applied to some specific on campus and off campus hospital departments. For that reason EMTALA regulations are continued to violate. If the communication of CMS is clear and practical then it will be easier for the providers to fall in line with EMTALA (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 4).

It is the responsibility of CMS to check violations against EMTALA and cancel the Medicare provider agreement if a hospital does not follow EMTALA regulaions (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).CMS reports confirmed violations to OIG so that monetary fines could be imposed on the hospitals or physicians in case of EMTALA violation. EMTALA violations and fines are not in great number and there very less cases in which Medicare provider agreements have been ended (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).Since 1995, 400 hospitals have been investigated for EMTALA violation and approximately half of them are found as offenders which are not complied with EMTALA regulations (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).CMS is making efforts to increase consistency among regions, which can support providers in their attempts to follow the regulations of EMTALA (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).In case of violation CMS terminates the hospital’s Medicare provider agreement in 23 to 90 days (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).

OIG takes many factors into consideration when it has to find out whether enforcement action beyond CMS is suitable or not. In considering factors it includes nature and situations of the breach of law and its impact on the hospitals’ ability for taking care of patients when the fines has to be decided. The OIG has penalized approximately $5.6 million on 194 hospitals and 19 physicians from 1995 to 2000 (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 6). Most of the hospitals penalties were $25000 or less than that. The total number of physicians who were penalized by the OIG for violating EMTALA regulations is 28 (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 5).

The OIG is very careful in deciding civil monetary penalties. OIG’s main concern is to support future compliance with EMTALA and discourage disobedience in relation with EMTALA regulations. After getting a case from CMS, OIG analyzes whether it has not followed the rules of EMTALA statute and if OIG finds that particular case has not voilated any EMTALA statute, it does not consider such cases. While making decision of the violation, It analyzes the effect of the penalty on the hospital’s ability to provide care (Emergency Care: EMTALA Implementation and Enforcement Issues, Para 33).

Works Cited

“EMTALA Implementation and Enforcement Issue”. GAO, 2001. Web.

“Emergency Medical Treatment and Active Labor Act — EMTALA Full Text”, 2005. Web.

Frew, Stephen A JD. “US Court Refuses to Dismiss EMTALA Case in Death of Discharged Patient”, 2007. Web.

Frew, Stephen A JD “Prosecutors Accuse Hospital of Stonewalling EMTALA Investigation”. 2007. Web.

Jourdain, William. “Swine Flu Pendamic V. EMTALA- How to meet the Challenge”. 2009. Web.

Schecter, Jennifer Coles. “COBRA Laws and EMTALA.” WebMD. 2009. Web.

“The Application of the Emergency Medical Treatment and Labor Act (EMTALA) to Hospital Inpatients”. 2009. Web.

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