Understanding EMTALA _The Emergency Medical and Active Labor Act_

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					Understanding EMTALA
(The Emergency Medical
 and Active Labor Act)

   [Insert Name of Presenter]



                        Ethics Resource Center
                        American Medical Association
         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 always
     be recognized as presenting valid claims
     for gratuitous services.”
                                   Ethics Resource Center
                                   American Medical Association
         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
       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
    The Government Steps In
• Hospitals built under the Hill-Burton Act
  (1946) were obliged to offer emergency
  treatment to those unable
  to pay.
• EMTALA, enacted in 1986, extended that
  obligation to all hospitals that participate
  in Medicare programs.

                                  Ethics Resource Center
                                  American Medical Association
      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
     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
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
     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
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
 Requirement 1: Medical Screening
  An emergency medical condition is the
  presence of acute symptoms of such severity
  that 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
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
Requirement 2: Stabilizing Patients
with Emergency Medical Conditions
 If an emergency medical condition exists, the
 hospital 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
           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
           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
      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
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
         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
           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
          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
          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
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
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
          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
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
      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
    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
This ethics educational presentation
        was created by the:

       Ethics Resource Center
    American Medical Association
       515 North State Street
          Chicago, IL 60610
       Phone: (312) 464-5257
         Fax: (312) 464-4799
      Email: erc@ama-assn.org
    Web: www.ama-assn.org/go/erc