You are in: eMedicine Specialties > Emergency Medicine > SPECIAL ASPECTS OF EMERGENCY MEDICINE COBRA Laws and EMTALAArticle Last Updated: Nov 15, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina Jerome FX Naradzay is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Coauthor(s): Joseph Wood, MD, JD, Consulting Staff, Department of Emergency Medicine, Mayo Clinic, Scottsdale Editors: Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Matthew M Rice, MD, JD, Vice President, Chief Medical Officer, Northwest Emergency Physicians, Assistant Clinical Professor of Medicine, University of Washington at Seattle; Assistant Clinical Professor, Uniformed Services University of Health Sciences; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School Author and Editor Disclosure Synonyms and related keywords: COBRA laws, Consolidated Omnibus Budget Reconciliation Act, COBRA, Emergency Medical Treatment and Active Labor Act, EMTALA, patient anti-dumping law, section 1867(a) of the Social Security Act, CMS, Centers for Medicare and Medicaid Services, Health Care Financing Administration, HCFA AN INTRODUCTION TO COBRA/EMTALASection 2 of 10
  Emergency Medical Treatment and Active Labor Act (EMTALA) requires a hospital to provide an appropriate medical screening examination to any person who comes to the hospital emergency department (ED) and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or an appropriate transfer to another medical facility. EMTALA was included in the Consolidated Omnibus Budget Reconciliation Act (COBRA) legislation of 1986. The initial intent of EMTALA was to address the alleged practices of some hospitals transferring, discharging, or refusing to treat patients who did not have insurance. It was alleged that hospital emergency rooms were denying uninsured patients the same treatment provided to patients with insurance or means to pay. Several cases seem to suggest that hospitals were "dumping" patients, that is, transferring patients to another hospital simply because the patient did not have insurance. EMTALA regulations apply to all hospitals that participate in the federal Medicare program. In order to be in compliance with EMTALA, the hospital must meet 2 primary obligations:
EMTALA regulations apply to anyone, not just Medicare beneficiaries, coming to a hospital seeking emergency medical services. EMTALA imposes financial penalties on physicians and hospitals. Additionally, the hospital, if found guilty of violating EMTALA regulations, can be excluded from participating in the Medicare program. The Act imposes 3 primary requirements on Medicare-participating hospitals that provide emergency medical services. The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a division of the Department of Health and Human Services. The CMS is responsible for the Medicare program and the development and enforcement of regulations on EMTALA. Proposed rules published in 1988 can be found in the Federal Register, June 16, 1988 (53 FR 22513). Interim final rules can be found in the Federal Register, June 22, 1994 (59 FR 32086). The authority supporting the statute is the taxing and spending clause of the Constitution. In essence, Congress has the right to demand certain services from vendors receiving federal tax dollars. In the EMTALA statute, obligations are tied to hospitals' participation in Medicare. In fact, a hospital could relieve itself of EMTALA obligations by dropping out of the Medicare program, although this certainly would not be financially beneficial for the hospital. No legislation requires federal hospitals to participate because they typically do not receive Medicare funds. Most federal hospitals, however, have voluntarily agreed to follow similar standards to screen, stabilize, and transfer patients. Physicians' EMTALA obligations are derived from their contractual relationship with a hospital. In the case of hospital-based physicians, the contract is one of employment or independent contractor. Other staff physicians also have EMTALA obligations. The contractual relationship between a doctor and a hospital is implicitly found in the Medical Staff By-laws or in the Medical Staff Rules and Regulations. The physician is presumed to know and accept these obligations concurrent with acceptance of staff appointment. CMS has issued the Final EMTALA Regulations effective on November 8, 2003. It is imperative that ED physicians be fully aware of their obligations under EMTALA regulations. EMTALA OBLIGATIONSSection 3 of 10
EMTALA delineates obligations for the referring hospital, the treating or transferring physician, and the receiving physician and hospital. These obligations are detailed in this article; the main points are as follows:
PATIENTS COVERED UNDER EMTALASection 4 of 10
Because the statute was enacted to remedy the perceived problem of denying care to indigent patients, some legal authorities initially applied the EMTALA statute exclusively to cases in which a patient was denied care because of indigence. In 1990, a federal district court in Kansas dismissed an EMTALA case because the plaintiff (patient) was neither indigent nor uninsured. Virtually every other federal district and appellate court examining this issue has relied upon the direct wording of the statute in finding "any individual who comes to the Emergency Department" to be eligible for protection under EMTALA. In fact, many recent EMTALA cases concerned violations of the statute in providing or denying care to patients insured by managed care organizations. Although the express wording of the statute appears to limit its application to patients who present to the ED, the courts and the CMS have interpreted this phrase broadly. Essentially, the hospital is obligated to follow EMTALA policy for any patient who is physically on its campus. Thus, a patient who bypasses the ED and is admitted to the obstetrics/gynecology department still is protected under EMTALA. A patient requesting emergency services from a hospital while in an ambulance may be diverted without violating EMTALA, since the patient has not physically "come to the hospital." However, if the ambulance is owned by the hospital, the CMS maintains that the patient is then on hospital property and consequently is covered under EMTALA. Additionally, a hospital operating a specialty service violates EMTALA by refusing to accept a transfer if facilities and staff could have been provided to care for the patient. MEDICAL SCREENING EXAMINATIONSection 5 of 10
EMTALA regulations apply to all patients in hospitals in the United States that receive payments for Medicare beneficiaries. Hospitals that are typically excluded from EMTALA regulations include the Shriners' Hospital for Crippled Children and many military hospitals. The obligation under EMTALA applies in the following situations: (1) A request for emergency services is made. This request can come from the patient, someone accompanying the patient, a law enforcement officer bringing someone to the ED for a blood alcohol level measurement, or someone walking into the ED requesting a blood pressure check. (2) A reasonably prudent layperson would conclude, based on the person's appearance or behavior, that the person is in need of emergency treatment. Applying this condition obligates all hospital staff to recognize when a visitor, another employee, or anyone on the hospital campus, is in need of medical assistance, ie, needs a medical screening examination. According to 2003 regulations, once the patient is admitted and stabilized, the EMTALA obligations end. EMTALA does not apply if, after admission, the patient develops a new emergency condition. The term medical screening commonly misleads physicians attempting to interpret their responsibilities under EMTALA. A triage evaluation does not satisfy the requirement to provide a medical screening examination. Case law and administrative regulations state clearly that the patient must receive an evaluation reasonably calculated to identify emergency medical conditions suggested by presenting signs and symptoms. This evaluation must include, if indicated, the use of diagnostic aids and specialty consultations normally available in the ED. Therefore, a patient presenting with fever, headache, and stiff neck may require CT scan and lumbar puncture as part of the medical screening examination. While neither the statute nor the regulations preclude a nurse or a physician extender from providing the required medical screening examination, compliance generally is ensured if a physician evaluates the patient. EDs that use nonphysicians to provide medical screening examinations must do so under a plan approved by its hospital's board of directors, although the HCFA has stated it is not bound by the board's determination and may rule, after the fact, that a physician should have evaluated a patient. Derlet et al reported on the experience of the University of California-Davis Hospital in using specially trained nurses to provide medical screening examinations to patients presenting to the ED. If an emergency medical condition was not identified, the patient was triaged out of the ED with referrals for an appropriate provider. Hospitals contemplating the use of a similar plan should consider the following:
EMERGENCY MEDICAL CONDITIONSection 6 of 10
An emergency medical condition is a medical condition that manifests as acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could place the individual's health at risk. The physician and hospital do not violate EMTALA by failing to treat an unidentified emergency medical condition despite a good faith evaluation. For example, assuming an appropriate evaluation was provided, no EMTALA violation will be found if an emergency physician discharges a patient with an acute myocardial infarction (MI) after erroneously concluding the patient's symptoms were attributable to chest wall pain. Once a physician diagnoses the patient's condition, however, appropriate treatment must be provided if the patient's health is at risk. Whether a given diagnosis or condition constitutes an emergency medical condition may ultimately be decided by a jury if an EMTALA claim is presented. Experts called by either party undoubtedly would assist a jury. In the example of a pregnant woman who is having contractions, an emergency medical condition exists if the transfer poses a threat to the health or safety of the woman or unborn child or if there is inadequate time to safely transfer her to another hospital. A pregnant woman delivering in the course of a transfer does not automatically constitute an EMTALA violation, although, at least one US Court of Appeals has warned that physicians and hospitals taking this type of risk may incur a "battle of the experts" in consequent EMTALA litigation. Emergency medical conditions also include psychiatric emergencies (eg, substance abuse, withdrawal syndromes). These patients must receive a medical screening examination calculated to identify underlying medical problems causing or contributing to their psychiatric condition. The patient may be transferred if the psychiatric condition stabilizes. The HCFA has stated that stabilization in some patients may require consultation with a staff psychiatrist. STABILIZATION AND TRANSFERSSection 7 of 10
Stabilization involves treatment of the emergency medical condition to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to result from the patient's transfer or discharge. Once a patient stabilizes, the hospital has no further EMTALA obligations and consequently may discharge or transfer the patient. Emergency physicians should know, however, that both the US Congress and the HCFA have intentionally created a very broad definition for the term stabilize. The key to applying this definition is that the patient's condition is considered stable within a reasonable medical probability. This is an objective standard. An EMTALA violation is not automatically found simply because a patient's condition deteriorated following discharge or transfer from the ED. Rather, the reviewing body (either the local peer review organization acting on behalf of the HCFA or a court), examines the facts known to the emergency physician at the time of the stability determination. Once again, the physician may be caught in a battle of experts. Unfortunately, no clear formula exists, in either the legal profession or the medical profession, to determine whether a patient's condition should be considered stabilized. For example, emergency physicians may disagree on whether a patient with a diagnosis of new-onset angina is stable enough for transfer, even though vital signs are normal and no ongoing chest pain is present. The astute emergency physician recognizes that the intent of the legislation is to promote cautious and conservative judgments before patient transfer or discharge. Moreover, even if a patient's condition is not clearly stabilized, the patient still can be transferred if the medical benefits exceed the risk or upon the patient's request. No further EMTALA obligations exist if an appropriate medical screening examination identifies no emergency medical condition. No further EMTALA obligations exist if an identified emergency medical condition is stabilized. Additionally, the latest regulations now recognize that a patient with an emergency medical condition may be discharged with a plan to have subsequent treatment provided as an outpatient if such a plan is consistent with medical routine and does not jeopardize the patient's health. For example, an extensor tendon laceration may be "stabilized" in the ED by providing an examination, wound asepsis, antibiotic prophylaxis, and dressing and by arranging for subsequent outpatient surgical repair. Patients with incompletely stabilized emergency medical conditions still may be transferred under EMTALA if 1 of 2 conditions exists, as follows:
Once a decision is made to transfer the individual, the following steps must be taken:
ENFORCEMENTSection 8 of 10
The EMTALA statute is enforced by the CMS and by private individuals bringing lawsuits based on a violation. The essential provisions are as follows:
From the enactment of the statute until December 31, 1993, approximately a third of all hospitals were investigated for alleged EMTALA violations. In about 25% of cases, an EMTALA violation was found. Civil monetary fines against physicians and hospitals have reached $150,000 for multiple violations. Medicare programs have been terminated at 11 hospitals. In addition to enforcement by the CMS, hospitals (but not physicians) may be named as defendants in private lawsuits from aggrieved patients. Under EMTALA, the patient is entitled to those damages available for personal injury under the law of the state in which the hospital is located. Usually, these EMTALA lawsuits accompany allegations of medical malpractice. A SUMMARY OF EMTALASection 9 of 10
EMTALA was enacted as a remedial statute intended to remove economic considerations from important medical decisions in the ED. Hospitals and physicians are required to provide appropriate evaluations to all patients. The scope of these evaluations may be very broad and should be reasonably calculated to identify emergency medical conditions. The hospital then must treat and stabilize identified emergency medical conditions or provide an appropriate transfer. An appropriate transfer of an unstable patient is limited to circumstances in which the medical benefits exceed the risk or the patient requests treatment at another facility. Enforcement of the statute by the HCFA and private individuals has been robust over the past 10 years. Physicians and hospitals probably will face increasing scrutiny for EMTALA compliance in the future. REFERENCESSection 10 of 10
Article Last Updated: Nov 15, 2006 |
