Understanding EMTALA (The Emergency Medical and Active Labor Act)

1. Understanding EMTALA(The Emergency Medical and Active Labor Act) [Insert Name of Presenter] Ethics Resource Center American Medical Association

2. Medicine’s 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

3. 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

4. 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

5. 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

6. EMTALA’s Purpose • To provide an “adequate first response to a medical crisis for all patients.” • Some translate EMTALA’s purpose as: “to prevent hospitals from dumping indigent patients.” Ethics Resource Center American Medical Association

7. 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

8. 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

9. 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

10. Requirement 1: Medical Screening • The emergency department must provide a medical screening exam to any patient who requests treatment (regardless of that patient’s 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

11. Requirement 1: Medical Screening An emergency medical condition is the presence of acute symptoms of such severitythat the absence of immediate medical attention could reasonably be expected to result in • Placing an individual’s health in serious jeopardy, • Serious impairment to bodily functions, • Serious dysfunction of any bodily organ or part. Ethics Resource Center American Medical Association

12. 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

13. 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. Ethics Resource Center American Medical Association

14. Requirements of Transferring Hospital • Provide medical treatment, if possible, to minimize the risk of transfer, • Obtain patient’s 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. Ethics Resource Center American Medical Association

15. 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. Ethics Resource Center American Medical Association

16. Requirement 3: Transfer of Non-stabilized Patients Non-stabilized patients may be transferred ONLY IF: • The patient (or someone acting on the patient’s behalf) requests a transfer in writing after being informed of the risks involved and the hospital’s duty to treat under EMTALA, or • A physician certifies that the medical benefits expected from transfer outweigh the risks involved in the transfer. Ethics Resource Center American Medical Association

17. 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. Ethics Resource Center American Medical Association

18. 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

19. 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

20. 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

21. 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 nation’s indigent and uninsured. Ethics Resource Center American Medical Association

22. 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 nation’s indigent and uninsured. • 42 million Americans are uninsured. Ethics Resource Center American Medical Association

23. 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

24. 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

25. 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. Ethics Resource Center American Medical Association

26. 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

27. Medicine’s 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

28. This ethics educational presentation was created by the: Ethics Resource CenterAmerican Medical Association515 North State StreetChicago, IL 60610Phone: (312) 464-5257Fax: (312) 464-4799Email: erc@ama-assn.org Web: www.ama-assn.org/go/erc