Revisiting the Emergency Medical Treatment and Labor Act, the Anti-dumping Law
Key takeaways:
The Emergency Medical Treatment and Labor Act, known as EMTALA, is a federal law that requires hospitals to treat patients’ emergency conditions regardless of their ability to pay or insurance status.
EMTALA imposes stiff fines for violations.
This is not meant to be legal advice. If you need legal help, contact an attorney in your state.
The Emergency Medical Treatment and Labor Act, or EMTALA, is a federal law that went into effect in 1986. The law’s purpose is to prevent hospitals from transferring uninsured or out-of-network patients to another facility without at least screening for and treating emergency medical conditions. As cavalier as it may seem, some hospitals would “dump” patients at other hospitals without stabilizing them or performing any screening tests or treatment. And that’s how EMTALA became known as the anti-dumping law.
EMTALA applies when a patient comes into the emergency room for an emergency medical condition. The patient must be stabilized before they’re transferred to an appropriate facility, unless certain circumstances are met. (A brief government summary of the act can be found here.) Let’s take a closer look at the terms included in the law and the law’s impact.
Terms in the Emergency Medical Treatment and Labor Act
Below are some of the terms included in EMTALA, along with how they are defined.
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Emergency condition
An emergency medical condition is defined as a condition with severe and acute enough symptoms that the patient’s health would be in jeopardy without immediate care.
Stabilized
A patient is considered stabilized when, within a reasonable degree of medical certainty, a provider can be sure that the patient’s condition is unlikely to deteriorate further upon transfer.
Although the law offers a definition, this is ultimately a matter of judgment, based on the patient's particular characteristics and circumstances.
Appropriate transfer
Under EMTALA, an appropriate transfer of an unstable patient may take place when a physician has certified that the benefits of the transfer outweigh the risks or when a patient makes a transfer request in writing after being informed of their rights under EMTALA.
At that point, there are other matters to address:
The hospital must provide continued care until the transfer, to minimize the risk to the patient, and provide copies of the patient’s medical records to the receiving facility.
The hospital must confirm that the receiving facility has the ability to treat the patient’s condition and has agreed to accept the transfer.
The transfer must be made to qualified personnel, who have access to the appropriate medical equipment to treat the patient.
Scope and purpose of the Emergency Medical Treatment and Labor Act
The law’s basic principles can be broken down into three main issues:
There needs to be appropriate medical screening for emergency medical conditions.
If there is an emergency condition, the patient needs to be stabilized, unless certain conditions are met.
After appropriate care, the transfer of a patient must be completed to a qualified facility that has the capability to treat the patient.
Under the law, there are strict criteria for the transfer of stable patients. EMTALA requires that when a transfer is made, it is made to a medical facility with qualified personnel and the necessary medical equipment for care. More specifically, this means that the facility has to have the proper hospital units and ancillary services, and that its personnel are trained and capable of providing the necessary services.
The law typically applies to hospitals and emergency departments. However, its scope goes beyond that to include physicians, urgent care clinics, and more. Again, its purpose is to avoid scenarios in which hospitals transfer patients elsewhere because of factors such as insurance and ability to pay.
Examples of the Emergency Medical Treatment and Labor Act violations
EMTALA fines are imposed for each individual violation and are reviewed on a case-by-case basis by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) after referral from the Centers for Medicare & Medicaid (CMS). Let’s look at a few relatively recent cases.
Psychiatric cases
In 2016, a Missouri hospital paid a $360,000 settlement for failing to adequately screen a patient with a psychiatric condition. The patient, who had not been treated or stabilized, was transferred to a nearby facility via a private vehicle and was hit by another car when exiting the vehicle.
After a thorough investigation, the HHS-OIG found that the hospital had implemented a transfer policy that resulted in multiple EMTALA violations. This policy led to 17 separate occasions of the hospital failing to properly screen for emergency medical conditions and thus improperly discharging and/or transferring patients.
In another situation involving psychiatric patients, in 2017, AnMed Health, a hospital system in South Carolina, paid a $1.3 million settlement for a case involving multiple EMTALA violations.
According to the HHS-OIG, dozens of patients were involuntarily committed to the emergency department for periods ranging from 6 to 38 days. The OIG ruled the patients’ psychiatric conditions to be emergency medical conditions, which triggered EMTALA protections. Instead of properly treating and stabilizing the patients, they were involuntarily held in the hospital.
These cases illustrate how EMTALA can be invoked to protect people with mental health conditions.
Obstetric case
In 2019, a California hospital reached a settlement agreement with the HHS-OIG for $20,000 for failing to properly screen for emergency medical conditions and provide stabilizing treatment to a pregnant woman. The patient had arrived at the hospital after having abdominal pain for 4 hours and exhibiting vaginal discharge. Despite this information, the hospital did not perform a vaginal exam or determine if the patient was in labor.
The hospital transferred the patient to another facility in a private vehicle. Tragically, the patient delivered the baby in the car, and by the time she got to a hospital, her baby had died. This case is a horrifying example of how failure to perform proper medical screening and treatment can result in the loss of life.
In September 2021, CMS issued a memorandum as a reminder and clarification that EMTALA applies to people who are pregnant or are experiencing pregnancy loss. The memorandum also states that physicians and hospitals cannot cite state law as a way around the proper screening requirements in labor-related conditions.
The impact of the Emergency Medical Treatment and Labor Act
A negative impact of EMTALA stems from the fact that it is an unfunded mandate from the federal government. While we can all agree that treating patients is of utmost importance, hospitals typically do not get reimbursed for care that is provided without payment or with little payment.
In January 2021, the American Hospital Association published an article that studied the cost of uncompensated care in the U.S. (Uncompensated care is when hospitals do not receive any compensation from the patient or insurance for rendered services and treatment.) Since 2000, this care has cost American hospitals $702 billion. EMTALA is one of the reasons that hospitals are burdened with uncompensated care, but it can also stem from financial assistance programs, uninsured patients, and other adjustments.
Although it is hard to quantify the number of lives that have been saved by EMTALA, the CDC published an interesting study that breaks down the number of emergency department visits in the U.S. In 2018, there were an estimated 130 million emergency room visits — about 39 visits per 100 people. This shows how many people EMTALA can affect.
The overall rate of emergency department visits per person in the U.S. has not really changed since that study. What’s more, the rate of emergency visits is much higher for people with Medicaid as compared to those with private insurance. This illustrates how important EMTALA is: Without it, patients with Medicaid or no insurance would likely be turned away at a high rate, jeopardizing their health and safety.
The bottom line
EMTALA is referred to as the anti-dumping law for a reason. The law protects patients from being sent to another facility without proper screening and treatment for urgent medical conditions that need immediate intervention.
Hospitals need appropriately trained staff and procedures in place to make sure patients are properly cared for before a transfer and to help avoid fines. Due to the number of emergency department visits each year, this law has a big impact on both patients and hospitals.
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