The Emergency Medical Treatment and Active Labor Act (EMTALA) was introduced because of concerns that patients who needed emergency medical treatment were being denied access to that treatment due to inability to pay (Schecter, 2010). The law basically requires any hospitals that receive federal funding to provide emergency medical care under specific circumstances. However, despite the clear language of the law, hospitals and healthcare providers continue to willfully violate EMTALA. This leads one to wonder whether a for-profit healthcare system compatible with the goals of the EMTALA, or whether a for-profit healthcare system increase the risk of EMTALA violations, putting the health of the nation's least advantaged citizens at risk. While a profit-driven healthcare system seems to increase the likelihood that indigent patients will not receive appropriate care, even with the EMTALA's protections, that does not mean that the EMTALA is not a valid and useful law. By tying EMTALA to Medicare funding, Congress has provided hospitals with a financial incentive to provide emergency services to the poor. It is obviously not a fool-proof system, since willful EMTALA violations still occur, but it has helped provide health-care access to at-risk populations.
EMTALA Violations in Healthcare
The Emergency Medical Treatment and Active Labor Act (EMTALA) was introduced because of concerns that patients who needed emergency medical treatment were being denied access to that treatment due to inability to pay (Schecter, 2010). The law basically requires any hospitals that receive federal funding to provide emergency medical care under specific circumstances. Accepting Medicare is a trigger requirement, because Medicare is supported by Federal funds. Moreover, because many hospitals receive a significant portion of their income from Medicare, that requirement means that most hospitals are not going to choose to opt out of being covered by the EMTALA by refusing to accept Medicare patients.
The pertinent part of the EMTALA is found in 42 U.S.C.S. § 1395dd (a), which provides that when a person presents to an emergency department "the hospital much provide for an appropriate medical screening examination…to determine whether or not an emergency medical condition exists" (42 U.S.C.S. § 1395dd (a)). Furthermore, if the person has a significantly serious medical condition, the hospital becomes obligated to stabilize the patient, if possible, before sending them on for further treatment. In some instances, this requires that the hospital treat the patient.
The law seems quite clear-cut. Its intention is clearly to ensure that no person is turned away from receiving emergency medical services because of a lack of ability to pay. However, the reality is that hospitals engage in EMTALA violations on a consistent basis. First, there is a disagreement about what type of scenarios are significant enough to constitute the type of medical emergency that prompts required treatment. Second, there is an issue with enforcement: what remedy can really help a person who has been wrongfully denied emergency medical care? These issues are critical, but they gloss over the fact that the EMTALA should be an unnecessary law. Health care providers may be partially motivated by money, but most of them go into their professions with the desire to help people. If health care providers want to help people, what would lead to EMTALA violations? This paper explores the idea that a for-profit healthcare system, which is focused on profits, increases the risks of EMTALA violations.
The goal of the EMTALA is to ensure that every patient presenting in an emergency room for emergency care gets evaluated, and treated if the presenting condition is one that constitutes an actual emergency. The goal of most hospitals is to make a profit while providing medical care to the community. There seems to be a clear-conflict in these goals. Is a for-profit healthcare system compatible with the goals of the EMTALA, or does a for-profit healthcare system increase the risk of EMTALA violations, putting the health of the nation's least advantaged citizens at risk?
A profit-driven healthcare system is not an appropriate way to ensure that the poorest citizens are able to get quality healthcare. Hospitals have no incentive provide care for the poor, because they will not get paid for that care. Furthermore, the fact that EMTALA only applies to emergency service providers means that emergency rooms are flooded with people with non-emergency health problems, seeking free access to healthcare for routine conditions. When they are turned away for healthcare for routine conditions, some of these conditions do escalate into the type of emergency conditions prompting immediate treatment. The entire system is unnecessary, and prevents emergency rooms from providing the type of treatment that they should provide: true emergency care for all patients presenting with actual medical emergencies. Removing the financial incentive from healthcare would allow doctors and other healthcare providers to focus on the treatment of the patient, without worrying about profit and loss margins. Therefore, the EMTALA is not a sufficient means to ensure healthcare for the indigent, and EMTALA violations will continue, despite the serious consequences that can attend those violations.
The way that the current health care system is structured seems adverse to the goal of the EMTALA, which is to ensure that patients in need of immediate health care are not turned away due to inability to pay. Much of health care has a marketing concept for its primary business philosophy. The problem with that is the marketing concept focuses on the commercial aspect of medicine, ignoring the human element. In fact, in an emergency setting, making money the primary decision-making factor in treatment decisions is not only a questionable medical practice, but may be highly illegal and is certainly very unethical (Bonnici, 2007).
One of the problems is that hospitals, while required to do the health screening for the EMTALA may not actually be compensated for that health-screening, even if a patient is insured. "Managed care has been a significant deterrent to EMTALA implementation. Administrative barriers interfere with patients getting the care they need in an emergency. Payment for emergency services is based solely on discharge diagnoses. This 'retrospective' denial places a financial burden on emergency departments because a complete evaluation and testing may easily have been justified by the presenting symptoms (e.g., chest pain turns out not to be a heart attack)" (Century Consulting, 2002). In addition to placing a burden on emergency room resources, this type of retroactive diagnosis can make it difficult for doctors to determine what type of health screening is possible. A person presenting with signs of a migraine could have a brain tumor, but it would be ridiculous to require all emergency rooms to treat migraines as potential brain tumors. However, it would be equally difficult for a patient to prove that his or her individual symptoms were enough to signify a more advanced health-screening.
In addition, it is important to keep in mind that not all bad medical screening practices amount to an EMTALA violation. "A negligent screening examination, malpractice issues or cases of a patient's refusing treatment do not invoke EMTALA violations unless evidence of hospital coercion can be offered. A poor patient outcome does not necessarily signal an EMTALA investigation and an EMTALA violation can be shown without evidence of a poor outcome" (Century Consulting, 2002). The burden for the patient to establish an EMTALA violation may be insurmountably high, given that these patients are not going to have the funds to access high-quality legal representation and probably lack the knowledge of how to protect their own rights.
The fact that EMTALA violations can be difficult to prove is reflected in the fact that there is significant evidence that willful refusal to treat patients, in violation of the EMTALA, still occur. In a study examining whether EMTALA violations were willful, Ballard et al. discovered that 34% of EMTALA citations involving emergency department personnel involved a willful refusal of screening or stabilization, while 24% reflected possible refusals of service (2006). This still indicates a significant level of EMTALA violation, despite the fact that hospitals and individual healthcare providers face significant punishments if they are found to have violated EMTALA.
While the immediate consequence of an EMTALA violation may help a hospital's financial bottom-line, by keeping it from helping a patient who cannot pay for care, the investigation into the consequences of an EMTALA violation cannot end when the patient is transferred or discharged. Instead, one must examine the real consequences to the hospital of an EMTALA violation. "EMTALA compliance is regulated by the CMS, a division of the Department of Health and Human Services (HHS). There are significant financial consequences for violating EMTALA rules. A hospital and/or the responsible physician may face individual fines imposed by the government as well as civil damages claims. Additionally, the hospital can be excluded from participating in the Medicare program, which may be financially devastating" (Schecter, 2010).
Moreover, in a time when so many Americans do lack access to healthcare, it is important to keep in mind that "EMTALA is the closest…