August 2001 Bulletin

EMTALA still puzzling

Physicians, hospitals uncertain about triage, follow-up care

More than 40 percent of physicians and 60 percent of hospitals are uncertain about the extent of their responsibilities to comply with the Emergency Medical Treatment and Active Labor Act, EMTALA.

The law requires hospitals that participate in Medicare to provide a medical screening examination to any person who comes to the emergency department, regardless of the individual’s ability to pay. If the hospital determines that the person has an emergency medical condition, it must provide treatment to stabilize the condition or provide for an appropriate transfer to another facility.

But when it gets to the specifics, some physicians and hospitals have questions about how a medical screening exam differs from the initial triage or a general exam, how EMTALA applies to certain on-campus and off-campus hospital departments and the extent to which they are obligated under EMTALA to provide follow-up care to emergency department patients.

Responding to medical community concerns that EMTALA has created burdens such as overcrowded emergency departments, the General Accounting Office (GAO) earlier this year reviewed a random sample of EMTALA investigation files and made site visits to regional officials of the Centers for Medicare and Medicaid Services (CMS).

The CMS told the GAO it is aware of the difficulty providers have encountered in implementing some aspects of EMTALA and that it plans to provide more guidance and reestablish an advisory group of EMTALA stakeholders.

In general, hospital and physician representatives told the GAO that EMTALA has been beneficial in ensuring access to emergency services and reducing the incidence of patient dumping. However, the overall impact of EMTALA is difficult to measure, the GAO said, because "there is no data on the incidence of patient dumping before its enactment, and the only measure of current incidents—the number of confirmed violations—is imprecise."

Since 1995, CMS regional offices have directed state survey agencies to investigate about 400 hospitals a year and have cited about half of them for EMTALA violations. From 1995 through 2000, the Office of the Inspector General imposed fines totaling more than $5.6 million on 194 hospitals and 19 physicians.

The GAO reported that "many hospital officials and physicians with whom we spoke said that the implementation of EMTALA adversely affects the efficiency and type of service provided to hospitals and physicians.

"For example, they told us that EMTALA has resulted in more people coming to the emergency department for nonurgent services, leading to overcrowding and delays. However, other factors, such as the growth of the uninsured population and the difficulty some managed care patients may have obtaining timely appointments with their personal physicians, can also explain the increase in emergency department visits."

The GAO noted that from 1994 to 1998, the U.S. population increased by about 4 percent and during the same period the number of uninsured American also increased. Emergency department visits nationwide increased about 5 percent.

The GAO said the number of emergency departments declined by 8 percent from 1994 to 1999.

Some hospital officials and physicians said that fewer physicians are joining hospital staffs and participating in emergency department on-call panels because EMTALA leads to on-call physicians providing uncompensated care. Hospital representatives said EMTALA hinders their ability to ensure that they receive payment for care because they cannot obtain insurance information before examining them, but GAO said hospitals can follow normal registration procedures which includes collecting insurance information.

Hospital officials and physicians said that some specialists are reducing the number of procedures that they have credentials to perform and are not seeking privileges at hospitals to avoid being on call.

The GAO said in the past physicians in certain specialties had inducements to join hospital staffs and provide on call services because they were dependent on emergency patients to build their practices. Today, they can perform many procedures in outpatient settings and gain patients through the managed care networks.

CMS comments on some EMTALA uncertainties

Following are some provider uncertainties and comment by the Centers for Medicare and Medicaid Services (CMS).

Uncertainty: How does the medical screening exam differ from triage or a general exam? CMS: Interpretive Guidelines say triage determines order in which patients will be seen, not presence or absence of an emergency medical condition.

Uncertainty: Whether the determination that a patient is stable for transfer or discharge ends the hospital’s EMTALA obligation or whether the hospital must also ensure follow-up care is provided. CMS: The requirement is fulfilled when a physician determines the patient is stable for transfer or stable for discharge. The regulations on transfer requirements only refer to patients who are unstable.

Uncertainty: Some hospitals and physicians believe CMS requires full-time coverage of a specialty if the hospital staff includes three or more physicians in that specialty. CMS: There is no rule linking extent of coverage with the number of specialists on staff. Physicians are not required to be on call at all times.


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