In 1986, the Emergency Medical Treatment and Active Labor Act known as EMTALA (Section 1867 (a) of the Social Security Act) and sometimes referred to as the "Patient Anti-Dumping Act" was passed by Congress and signed into law by President Reagan. The purpose of the Act was to ensure that acutely ill patients who are uninsured or underinsured receive appropriate emergency care and to prevent hospitals from refusing to treat certain populations of patients who present to the emergency department. Although EMTALA was passed to protect those who lack financial resources or medical insurance, it applies to all seeking care from a hospital's emergency department in all states and territories of the United States. However, not all hospitals have obligations under EMTALA. Only hospitals that accept federal funds from the Centers for Medicare and Medicaid (CMS), a branch of the Department of Health and Human Services (HHS), are subject to civil liability under the Act. The CMS and the Office of the Inspector General (OIG) enforce EMTALA. The OIG can fine Hospitals $50,000 per violation ($25,000 for hospitals with less than 100 beds) and possibly terminate their Medicare provider agreement. Individual physicians also may receive a fine up to $50,000 and be excluded from future Medicare funding.
The "duty to treat" that EMTALA imposes on hospitals with emergency rooms that accept Medicare and Medicaid reimbursement begins when a patient comes to the emergency department seeking help. In addition to the emergency department, EMTALA also applies to other properties owned by a hospital, such as ambulances. To comply with EMTALA, the participating hospitals must provide within its capabilities a nondiscriminatory medical screening examination (MSE) to determine if the patient has an emergency medical condition. An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity, such as severe pain, for which the lack of immediate medical attention could reasonably be expected to result in placing the patient in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part." [Smith, JM, "EMTALA Basics: What Medical Professionals Need to Know," Journal of the National Medical Association 94,6 (2002): 426-429]. In the case of pregnant women in labor, an emergency medical condition exists if there is not sufficient time to deliver the baby at another facility or if the unborn child is at critical risk and needs assistance. If an emergency medical condition exists, the hospital must provide the necessary medical treatment to stabilize the patient. Legally, a patient can be considered stabilized when "no material deterioration of the emergency medical condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual, or, …that the (pregnant) woman has delivered (including the placenta)." [42 U.S.C. § 1395dd(e)(3)]. If no emergency medical condition exists or the emergency medical condition has been stabilized, then the hospital has no further obligation under EMTALA.
Hospitals regulated by EMTALA generally may not transfer an individual who has an emergency medical condition, unless the patient requests transfer or for a valid medical reason, such as a lack of resources that lead to an inability to further stabilize the patient. In cases in which a patient needs to be transferred due to the absence of necessary resources, specific parameters guide the transfer: 1) written informed consent of the patient or by the legal guardian must be obtained; 2) the medical benefits of the transfer must outweigh the risks and must be documented; 3) the receiving facility must assure that it has the capacity and capability to treat the patient; 4) all medical records must be sent to the receiving hospital; and, 5) transfer with the appropriate qualified personnel and transportation equipment must be arranged. Under EMTALA, the receiving hospital cannot refuse a patient in need of further stabilization if it has the capabilities.
Additional obligations may also exist for hospitals regulated by EMTALA. For example, hospitals may also have to provide on-call physician specialists, since their services may be essential to the emergency department's capability to determine the presence of an emergency medical condition. Hospitals also are obligated to report any patient transfers that they believe to be unsafe or inappropriate. Emergency personnel should report suspected violations to the hospital administrator, legal counsel or risk management department according to the hospital's EMTALA compliance plan. The obligation to report violations to the CMS applies to hospitals receiving a patient transfer, as well.
Even though the intent of EMTALA is to protect the poor and uninsured, particularly from discriminatory practices, it has several limitations from an ethical perspective. First, it does not substantially improve access to healthcare for the poor and underinsured. Rather, it represents only a second best approach by imposing civil penalties and loss of federal funds on hospitals that refuse to treat the uninsured in an emergency setting. Once the patient is stabilized, the hospital has no further obligations under EMTALA. Second, EMTALA does not establish a national standard of care in screening patients. Rather, it only requires an "appropriate" screening "within the capability of the hospital." As set forth by the federal courts, the crucial test "is not the adequacy of the screening and transfer process, but whether the evaluation, stabilization, and disposition of the patient deviated from the hospital's customary procedures for patients with similar emergency medical conditions." [Mitchiner, JC, Yeh, CS, "The Emergency Medical Treatment and Active Labor Act: what emergency nurses need to know," Nursing Clinics of North America 37(1) (2002): 19-34]. Third, EMTALA indirectly creates a legal obligation to provide life-sustaining treatment in situations where such treatment would not necessarily be considered morally obligatory or might even be considered futile. See, for example, the case of Baby K.
[Other sources: Furrow, BR, Greaney, TL, Johson, SH, Jost, TS, Schwartz, RL, Health Law; cases, materials and problems, American Casebook Series, West Group, St-Paul, Minnesota (1997):1247; Furrow, BR, "An overview and analysis of the impact of the Emergency Medical Treatment and Active Labor Act," Journal of Legal Medicine 16,3 (1995): 325-355.]
