Monday, April 4, 2016

Why Patients Still Need EMTALA

Recently, hospitals have been coming under scrutiny for violations of the federal Emergency Medical Treatment and Active Labor Act (EMTALA). This past December, Bon Secours St. Francis agreed to pay a $100,000 civil penalty to settle allegations that it violated EMTALA by improperly transferring the two gunshot victims, even though it had the capacity to treat them. The benefits of the transfer did not outweigh the risks and unnecessarily placed their health at further risk, according to HHS' Office of the Inspector General.

EMTALA, known as the patient anti-dumping law, was signed into law 30 years ago in response to national outrage over a surge in community hospitals transferring unstable emergency patients—including women in labor—to public hospitals and academic medical hospitals, largely for financial reasons.

EMTALA requires Medicare-participating hospitals to screen patients for emergency medical conditions and provide stabilizing treatment, regardless of their ability to pay. Hospitals with specialized capabilities must accept appropriate transfers to provide stabilizing treatment. The law does not require providers to continue treating patients once they are stable, nor does it generally apply after someone is admitted as an inpatient.

Hospitals found in violation of the law potentially face a $50,000 civil fine per incident, and can be barred from the Medicare and Medicaid programs. The law also gives dumped patients or their families the right to sue the provider.

The unfunded mandate signed into law by President Ronald Reagan sharply reduced cases of hospitals refusing to treat ED patients without insurance. Experts blame poor communication and inadequate training for most of the remaining incidents.

EMTALA—whose basic requirements are posted on the walls of every hospital ED—is widely credited with sharply reducing the number of cases of hospitals dumping or avoiding uninsured or underinsured patients.

Despite the law's positive impact, about 200 complaints a year are found to have merit. While that represents a tiny fraction of the more than 136 million annual emergency department visits in the U.S., there's broad agreement that the law continues to play an important role.

Yet, EMTALA is resented by hospital administrators and some physicians for its failure to finance its mandate. Experts say there are a variety of reasons why violations of the law continue to occur. Factors include pressure on hospitals to improve their finances, poor staff training, flawed systems and processes, communication mishaps, growing challenges in getting specialty physicians to be on-call to the ED, and a lack of inpatient beds and community resources for serving mentally ill patients.

The impetus for EMTALA was an epidemic of patient transfers that were widely seen as inappropriate and dangerous for patients, including pregnant women in labor being turned away from emergency rooms. Studies showed that in the early 1980s, there were about 250,000 transfers a year from private hospitals to public or Veterans Health Administration hospitals.

But EMTALA is no guarantee of appropriate emergency care. From 2002 to 2015, the CMS conducted 6,035 investigations of EMTALA complaints against hospitals and physicians—an average of 431 a year, according to a new study in the Western Journal of Emergency Medicine. The CMS found violations in 2,436 of the complaint cases it surveyed in conjunction with state agencies—an average of 174 a year.

To keep their Medicare certification, hospitals found in violation must submit a corrective plan, which the CMS reviews and approves. The agency then forwards those cases to the OIG for possible civil monetary penalties.

Of the cases referred to the OIG from 2002 to 2015, 192 resulted in settlements, including eight by physicians, according to the study. The most common citations were for failure to screen (75%) and stabilize (42.7%) for emergency conditions. Patients were turned away from hospitals for financial reasons in 15.6% of cases.

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