12 April 2011

Happy Birthday EMTALA?

Apparently it was 25 years ago that President Reagan signed the COBRA bill into law, which contained the EMTALA provisions. How time flies!

EMTALA has been an incredible double-edged sword for Emergency Departments and for the healthcare system in general. It has by far been the most transformative piece of healthcare legislation since medicare itself was enacted. Off the top of my head, for better and for worse:

It's protected patients. There were rampant abuses of patients who were less lucrative prior to EMTALA. Patients were turned away at the doorstep, refused care, wantonly dumped on neighboring facilities who operated on a "Good samaritan" basis, if there were any. It's given patients the ability to choose the institution they will get their care at, knowing they can't be railroaded against their will, and that needed care will be provided. That's an unmitigated good thing.

Created de facto universal health care, albeit limited, inefficient and incomplete. Any person, of any economic or legal status can walk into an ER and know they will get necessary emergency care, if there is a need. Not so great for chronic or non-emergent conditions, and not great for preventative care or post-acute care. Obligates not just ER doctors but specialists to provide needed care.

Indirectly increased access to emergency care by knocking down barriers raised by insurers. This was not immediate, but EMTALA was the club wielded to limit requirements for pre-authorization of ER services, and ultimately paved the way for the national "Prudent Layperson" standard.

Forced hospital ERs to embrace their role as community service centers and as the ultimate social safety net. This was accepted eagerly by some hospitals, more reluctantly by others. It has, however, given EM as a specialty the ability to wear the white hat, has given ER docs tremendous credibility and respect as the guys who will always do the right thing for the patient.

It's been an enormous unfunded mandate, which has forced many individual docs to work for free, and hospitals to provide charity care. The (un)fairness of this is one matter, but the practical effect has been that ERs where the EMTALA burden is higher are underfunded, poorly staffed and poorly capitalized. The requirement, without real funding to support it, has created a two-tier healthcare system where hospitals in less affluent areas struggle to provide critical and necessary services, and patients experience tremendous delays in care and poorer outcomes. Additionally, the unfunded mandate puts stress on specialists who are needed to provide on-call backup. On-call duty by its nature is unpleasant and disruptive, and the fact that it often becomes unpaid work increases this stress, to the point that many ERs can no longer maintain adequate specialist back-up. This affects all patients, regardless of insurance status, if there is no specialist to provide needed care.

Enabled the abuse of the ER for non-emergent complaints. Under EMTALA, if a patient presents with a clearly trivial or chronic complaint, the ER cannot turn them away, at least not without providing the mandated medical screening exam. While it is possible to short-change the exam and redirect/rebuff the patient at the front desk, this is infrequently done and fraught with risk. The practical matter is that the patient has to be registered, triaged and screened by a medical provider no matter what. At that point, in most cases, it's easier to finish treating the patient for their hangnail, medication refill or what-not. It has created a situation where the patient reasonably expects that they can receive care for anything at any time in the ER, thereby transforming our function from acute and critical care into convenience care. I cannot count how many times I have seen people in the ER who had access to more appropriate venues of care just because they didn't want to wait for an appointment or overcome with the hassles of dealing with office staff. It doesn't help that ACEP, in its efforts to justify our work as lifesaving and critical, falsely minimizes the tremendous amount of non-emergent care provided in the ER by repeating and publicizing misleading factoids. EMTALA, while it opened the ER to all, also precluded ERs from filtering out the patients who didn't need to be in an ER.

I could go on, but I won't. I'm sure you all can provide some other unanticipated effects of EMTALA in the comments. On the whole, I'd judge EMTALA as a good and successful law, though grievously flawed and in need of amendment.

Now don't even get me started on HIPAA.


  1. Could Congress just offer some additional public funding for non-emergency care that ends up being done in the ER? If people are already conditioned in many areas to go straight to the ER for care, it might be cheaper and easier to do that instead of trying to fund and promote separate clinics/programs.

    I'm probably missing out on something critical there. Flame me if you want to.

  2. I know of a young woman with rhabdomyolysis of unknown origin. The disease was getting worse and worse, and she was too weak to be placed in a car and driven to a university hospital. The community hospital could not get a university to take her even though their expertise was needed, because she had no insurance and the universities are too busy trying to stay afloat with all the unfunded care coming in through the ED. Her attending was terrified that she was going to die without getting the higher level care that she deserves.

  3. the solution is tax writeoffs and legal immunity for emtala care given out

  4. EMTALA is yet another government regulation that needs to go away forever. Since every emergency department wants to turn medicine into a customer service industry (like hotels and restaurants) with their patient satisfaction metrics, why shouldn't patients have to pay for services when showing up to the ED (within reason)?? I have to pay for my meal at any restaurant. I have to pay for my hotel room before I check out. I have to pay my vet bill everytime I bring my dog there. I had a 3 day critical care stay for my dog at a local vet which cost me $4000 - guess what? I had to pay them the full amount at the end of the stay before we left. Ditch EMTALA immediately.

  5. Insightful post, but it might minimize the impact of EMTALA on healthcare costs; in particular, on the development of cost-shifting -- the process by which hospitals attempt to recoup the cost of some of the free care they must provide through higher charges across the board to insured patients.

    And, quite frankly, I think EMTALA has been amended -- the amendment is called the Affordable Care Act of 2010.


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