EMTALA: Things You Never Knew (or Never Thought to Ask)

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Happy birthday, EMTALA! The law that revolutionized emergency medicine turns 30 this year. We all know the basic tenets of this legislation: provide medical screening exams, stabilize emergency medical conditions, transfer to a higher level of care as appropriate — and do all this without regard to ability to pay. But what about the finer points of this complex law? Read on to learn about a few of EMTALA’s lesser-known features and what effect it has had on medicine as we know it.

Medical Screening Exam

To start, EMTALA technically applies only to hospitals that accept Medicare or Medicaid and have emergency departments. This ends up being most hospitals, but not all of them. VA and military hospitals are exempt, and EMTALA does not apply to urgent care centers unless they are affiliated with a hospital.

Emergency departments are required to offer a medical screening exam to anyone on or within 250 yards of any hospital property who either asks for medical help, or who doesn’t ask but looks like they need it. That woman who lost consciousness in the hospital parking garage? The guy who got mugged in an alley a block away? The schizophrenic running around naked in the hospital lobby? All require a medical screening exam under EMTALA, even though none of them technically came to the ED asking for help.

Who can actually perform the medical screening exam? The law leaves this decision up to hospitals, but it is usually attending physicians or NPs/PAs under attending supervision. Nurses never qualify, and residents hardly do either. If the medical screening exam reveals that no emergency medical condition is present, technically the obligation to treat without regard to ability to pay has ended, and you can either discharge the patient or ask for prepayment before further care. However, since lawyers can retroactively decide whether an emergency medical condition was present or sufficiently stabilized, it is best to just keep treating the patient.

Transfers

It is appropriate to transfer a patient when s/he requires resources that you cannot provide (for example, a subarachnoid hemorrhage at a hospital with no neurosurgery). The receiving hospital must accept the patient if it has space and qualified personnel available. “Space” in this context means the hospital is operating at a typical capacity; for example, if your ED usually sees patients in the hallway, you cannot refuse a transfer due to having too many hallway patients already. “Qualified personnel” means that if your hospital has ever treated a similar patient, you are considered to have the expertise available. Even if the trauma team has already taken 4 gunshot wound victims to the operating room tonight, you must accept the 5th gunshot wound victim as a transfer. The caveat is that patients must be stable enough to transfer, meaning no active arterial bleeding or impending airway compromise, no active labor, etc.

Transfers must take place using appropriate personnel and equipment (ie, an ambulance instead of a private vehicle), and all relevant medical records must be transferred as well. The last time a patient arrived from an outside hospital without the CD of the computerized tomography scan they did over there? That is an EMTALA violation punishable by a $50,000 fine.

Consultants

Bottom line: If a medical specialty is available in the hospital at any point during the week, it must be available to the ED 24/7. Consultants must see the patient in a timely fashion, but EMTALA lets us decide what “timely” means. Consultants must also provide outpatient follow-up care without regard to ability to pay, since this is considered part of the stabilization process for an emergency medical condition. Unfortunately, telemedicine is not yet acceptable to meet EMTALA requirements.

Effect on Health Care

EMTALA transformed the ED from a place strictly for emergencies into America’s safety net. The requirement to treat everyone before getting payment (and often never getting payment) has not only contributed to ED overcrowding, but also imposed a huge burden of uncompensated care upon hospitals – to the tune of billions of dollars each year. There is no provision in EMTALA to address this unintended consequence, in effect making it the largest unfunded mandate ever imposed on the health care sector.

However, EMTALA also established health care as a right for all people, not a privilege afforded only to the rich. It has additionally saved countless lives by preventing the transfer or rejection of medically unstable patients.

The Future of EMTALA

While there are several ongoing efforts for reform, a clear unified solution is far from actualization. If you are interested in getting involved and learning more about this and other health policy issues, please consider joining EMRA’s Health Policy Committee. Email healthpolicyctte@emra.org for more information. Or, visit the Health Policy Committee website on emra.org.

We also encourage you to attend the ACEP Leadership & Advocacy Conference in Washington, D.C., May 15-18. Learn how to campaign for the betterment of our patients and our specialty. Many states sponsor residents to attend, and we would love to see you there! Register at acep.org/lac.

Elizabeth Davlantes, MD

Elizabeth Davlantes, MD

Resident Physician, Emory University, Atlanta, GA
Elizabeth Davlantes, MD

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Ross Christensen, MS-IV

Ross Christensen, MS-IV

Osteopathic Coordinator, EMRA MSC | Des Moines University | Des Moines, IA
Ross Christensen, MS-IV

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