The Emergency Medical Treatment and Labor Act (EMTALA)

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted to prevent patient dumping. It provides patients a considerable amount of protection and leverage in obtaining care under emergency situations. The reimbursement strictures imposed by managed care organizations have compounded the problems. This article summarizes the Act's definition of role and duties of hospitals and physicians and the regulations to which these parties must adhere or face significant penalties.     

Patient wins skirmish against hospital for forced HIV test

A gay man who was forced to submit to an HIV test before doctors would perform an emergency appendectomy survived a motion by the defendants for dismissal. The plaintiff is suing the physicians, hospital, and nurse for violations of the Federal Emergency Medical Treatment and Active Labor Act (EMTALA), which bars "patient dumping" in emergency rooms. The plaintiff went to the Overland Park Regional Medical Center in Kansas because he had pain in his lower right abdomen. The defendants believed EMTALA was designed to prevent delays in treatment related to a patient's ability to pay. However, the judge ruled the plaintiff was seeking relief under a different section of the provision that prevents emergency rooms from engaging in disparate medical screening procedures. The nurse and the hospital escaped liability on the tort claims.     

Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare‐participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted 11 semistructured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested 5 methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA‐compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest (1) more closely aligning Medicaid/Medicare payment policies with EMTALA, ( 2) amending the Act to permit informal mediation between hospitals about borderline violations, (3) increasing the hospital's role in ensuring EMTALA compliance, and (4) expanding the role of hospital associations.     

Fixing EMTALA: what's wrong with the Patient Transfer Act

Congress primarily enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 to prevent the denial of care to uninsured patients in emergency departments. The final version of EMTALA lacks specific protection for indigent patients and saddles hospitals and physicians with more liability than Congress initially intended. Loopholes in the law allow denial of care to patients when temporarily stabilized. Congress should ameliorate these problems through amendment of the law.     

EMTALA obligations for psychiatric patients

The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 and governs the obligations of licensed hospitals that participate in the Medicare program with respect to patients with emergency medical conditions. Psychiatric units and facilities often believe that it does not apply to them, or they are cavalier in their efforts to comply with it. If the entity is a licensed hospital, or operates within a licensed hospital, that participates in Medicare, the Act is fully applicable to them. Such entities disregard EMTALA at their peril.     

Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

Cops and docs: The challenges for ED physicians balancing the police,state laws,and EMTALA

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers.     

临床医师与医学生对患者相关权利的认知调查

目的：了解医院医务人员对相关法律法规知识的认知程度,为完善医院相关管理制度提供依据。方法运用随机抽样的方法选择某大学附属（三级甲等）医院临床医师与医学生,采用问卷调查方式对诊疗环节中涉及到的患者权利法律法规认知情况进行调查研究。结果临床医师对甲类传染病应对措施和对患者隐私保护了解程度普遍比学生高,而中级医师对首次病程记录时间回答错误率高达93.6％。5类调查对象对诊疗义务及事故后果所需承担的法律责任了解程度多集中在了解上。结论医院需要加强临床技能培训,规范病历书写,加强医患沟通,并需要强化医务人员的法制意识、法律知识的学习和法定义务的认知。完善医院建设,减少医疗纠纷的发生。     

Learning the developments in EMTALA jurisprudence through the lens of John West's “case law update”

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an “appropriate” medical screening examination; second, when is a patient actually “stabilized’ under EMTALA; and third, does the EMTALA obligation really “disappear” when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to “get it right” on the law and that drive risk managers crazy. EMTALA is the “poster child” for such a topic.     

Physician Staffing of Small Rural Hospital Emergency Departments: Rapid Change and Escalating Cost

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals.     

Case Studies At Denver Health: 'Patient Dumping' In The Emergency Department Despite EMTALA, The Law That Banned It

The Emergency Medical Treatment and Labor Act was enacted in 1986 to prevent hospitals from turning away patients with emergency medical conditions, often because they were uninsured-a practice commonly known as "patient dumping." Twenty-five years later, Denver Health-a large, urban, safety-net hospital-continues to experience instances in which people with emergency conditions, many of whom are uninsured, end up in the safety-net setting after having been denied care or receiving incomplete care elsewhere. We present five case studies and discuss potential limitations in the oversight and enforcement of the 1986 law. We advocate for a more effective system for reporting and acting on potential violations, as well as clearer standards governing compliance with the law.     

Your money or your life: 'dumping' uninsured patients from hospital emergency wards.

Annas argues that current public policy that emphasizes cost containment over quality of care and equity of access is an effort to transform medical care from a social good to an economic good. This trend threatens to erode the community ethic of providing emergency care to all regardless of ability to pay. The author cites statistics and cases that reveal a trend by hospitals to deny emergency care or to transfer medically unstable patients for economic reasons. Courts have upheld the right to emergency treatment and physicians, who determine what is an emergency, are urged to oppose hospital policies that compromise patient care and to reaffirm their ethical stance. The author concludes that state regulations should define emergency broadly, develop "emergency transfer protocols," and provide for sanctions against institutions and personnel that violate them.     

Technology acceptance as an influencing factor of hospital employees’ compliance with data‐protection standards in Germany

Aim

Data-protection regulations in German hospitals, based on data-protection laws and internal regulations, must be complied with and taken into account in daily work. However, these regulations are not always respected, as evidenced by the data-protection scandals in Germany of recent years.

Subjects and methods

In a 2010 survey, data was collected from 557 individuals including administrative staff, nursing staff, physicians, physicians with scientific/research-based work and other health professionals of 26 hospitals in Germany to analyze the factors of relevance with regard to data-protection compliance.

Results

The acceptance of hospital staff concerning data-protection regulations is significantly influenced by subjective values and personal attitudes. Significant differences related to the acceptance of data-protection rules and regulations can be found in gender or type of hospital. The results show that employees consider rules and regulations to be necessary and important. However damage caused by data security breaches and the likelihood that they will occur, are considered to be less significant. A large impact on individual data-protection compliance can be reported in the subjective norm, which is influenced by the effect of close colleagues and superiors.

Conclusion

The underlying results of the study at hand demonstrate practical implications which can lead to a high degree of data-protection compliance in the future. The related aspects deserving future investigation of the possible explanations for differences in behavior related to data protection among various occupational groups in hospitals are discussed. Men and women exhibit very different levels of data-protection acceptance, so future efforts to increase sensitivity and awareness of data-protection issues in employees require gender-specific approaches. Another issue that merits investigation is the source of the influence of hospital type on data-protection compliance.     

Characteristics of the work of consulting psychiatrist at a non-psychiatric hospital

According to the findings of different authors somatic emergency hospitals admit about 0.3-40 percent of patients with psycho-somatic diseases: mental patients suffering from acute somatic diseases, patients with somatically conditioned mental disorders and also patients the somatic complaints of whom are manifesting symptoms of mental disease. An analysis was made of the consulting psychiatrist work at the multidisciplinary emergency hospital which had no somatopsychiatric department (SPD) in its structure. Medical care was provided to 2654 "mixed patients" with different mental disorders. Acute psychotic symptomatology was detected in 38 percent of these patients, however only 3.42 percent were transferred into mental hospitals and SPD of other hospitals. The remaining patients stayed at somatic hospital up to the end of treatment due to non-carriageable condition. Such situation considerably compicates the work of consulting psychiatrist. The optimization of curative and rehabilitative care for the patients requires efficient cooperation between consulting psychiatrist and resident physicians providing diagnosis, complex biological therapy, differentiated curative and rehabilitative regimen and also securing the rights of mental patients for confidential care in accordance with Code of medical ethics and ensuring continuous upgrading the skills of nurses and physicians of somatic hospitals.     

基层医院急诊建设及管理的探讨

本文探讨基层医院急诊建设、急诊管理及急救人才培养策略。从不同方面阐述了基层医院急诊科目前存在的诸多问题：如没有固定编制,开展工作以“完全依赖型”为主,劳动强度大、待遇低、纠纷多、易受暴力威胁,职称晋升困难,人员流动性大等。针对这些问题,提出了切实可行的解决办法：基层医院建立“支援型”急诊科,以现代急诊医学新的“三环理论”指导急诊日常工作,积极开展院前急救,加强院内急救力量,建立急诊重症监护病房,千方百计拓展和延伸急诊服务,方便患者;建立健全规章制度,严格落实,确保安全;加强人才培养,提高职业素质,建设全科医学模式急诊科,提高抢救成功率,增加社会效益。为基层医院急诊建设及管理提供经验。     

提高综合性医院传染病疫情报告质量的方法研究

[目的]寻求提高综合性医院传染病疫情报告质量的方法.[方法]根据荆门市第一人民医院的实际情况,按照《中华人民共和国传染病防治法》及《实施细则》的要求,制定医院传染病疫情报告管理规范和实施意见并组织实施.[结果]传染病报告人数有了明显增加,报告及时率、报告完整率有了显著提高,漏报率显著下降.[结论]提高综合性医院传染病疫情报告质量,领导重视是关键,明确责任是前提,狠抓落实是重点.     

Factors contributing to patient dumping in Taiwan

OBJECTIVE: Little research has been carried out to explore the issues surrounding patient dumping outside of the US. This study, therefore, uses a national research survey to examine the factors contributing to patient dumping within Taiwan. METHODS: A self-administered postal survey was undertaken to assess the prevalence of patient dumping in Taiwan, with the study subjects being superintendents of general hospitals. Data from the Bureau of Medical Affairs at the Department of Health in Taiwan were used in conjunction with the Taiwan National Health Insurance Research Database (NHIRD) to obtain estimates of factors potentially contributing to patient dumping. A multiple logistic regression analysis was performed to determine the relationships between the perceived extent of patient dumping occurring within the respondents' healthcare networks, as well as other factors, including the total number of hospitals, total number of hospital beds, the percentages of beds in public, for-profit and teaching hospitals (vis-à-vis all hospital beds), discharges, discharges covered under the case payment system, transferred inpatients, and the perceived degree of competition within each healthcare market. RESULTS: A total of 485 survey questionnaires were distributed, of which 251 were returned, giving a response rate of 51.75%. The responses from 29.9% of the sample group indicated that the perceived extent of patient dumping occurring in their service area was 'serious' or 'very serious'. The regression analysis showed that after controlling for other factors, the superintendents' perceived extent of the patient dumping occurring within their healthcare networks was positively related to the total number of patients covered under the case payment system, the total number of discharged patients, the extent of healthcare market competition and the number of respondent's hospital beds. CONCLUSIONS: We conclude from our findings that, under the National Health Insurance system, patient dumping is a widespread problem within Taiwan's healthcare industry.     

New Jersey hospital wins the battle, but loses the war

Memorial Medical Center of South Amboy, N.J., was forced to close its doors and give up its license to operate as an acute care hospital. But a consortium of physicians and business people in the north central New Jersey city decided they couldn't do without the hospital's emergency service and attempted to reopen it. At the same time, the state's health department completed a report that found the state's 83 acute bed hospitals were "over-bedded" and refused to renew Memorial's license. This led to court actions and negotiations between the hospital and the state. The hospital's supporters mounted a major public relations blitz that reached the state capitol in Trenton. The campaign was successful in forcing negotiations, but the hospital was only allowed to provide emergency service as a satellite of a neighboring hospital.     

Obtaining advance beneficiary notices for Medicare physician providers

Medicare has established medical necessity rules that define the medical conditions that make beneficiaries eligible for particular services. These rules are codified in local medical review policies (LMRPs) that are established by Medicare claims payment contractors. If a beneficiary's provider does not inform the patient that a service may not be covered, the provider cannot subsequently bill the beneficiary for the service if it is denied. This article discusses the application of these policies. It illustrates the circumstances in which advance beneficiary notices (ABN) are required to ensure that patients have been notified that services rendered will not be covered by Medicare and will become their financial responsibility. The author also presents special applications of the ABN regulations as they apply to the EMTALA rules, anti-kickback, and other statutes. Samples of the official ABN forms are illustrated.     

Court decisions side with continued treatment of medically futile cases

Confusion reigns in the care of two medically futile cases as one state's supreme court requires hospitals to ask the local state attorney's office to arbitrate conflicts between "acceptable medical treatment and the patient's wishes," and another court applies the federal Emergency Medical Treatment and Active Labor Act (EMTALA) to require a hospital to stabilize an anencephalic child's respiratory distress.