In a new report, the General Accounting Office (GAO), Congress’ watchdog agency, generally stands by the Department of Health and Human Services’ (HHS) interpretation of the Emergency Medical Treatment and Active Labor Act (EMTALA). The GAO also places faith in the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) to clarify provisions that bedevil providers.
The medical community is concerned that EMTALA creates burdens for hospitals and physicians such as overcrowded emergency departments. EMTALA requires emergency rooms to furnish screening exams and stabilizing treatment to patients with emergency medical conditions regardless of their ability to pay. (AANS Bulletin Vol. 9, Spring 2000.) Hospitals must start treatment before checking insurance status, and they must follow rules when they transfer patients to hospitals that are better equipped to deal with a particular condition. The rule was expanded in 2000 to cover a main hospital campus and off-campus provider-based facilities.
Lack of Dumping Data
The GAO report, titled EMTALA Implementation and Enforcement Issues, states that hospital and physician representatives say that EMTALA has been beneficial in ensuring access to emergency services and reducing the incidence of patient dumping. The GAO concludes, however, that the overall impact of EMTALA is difficult to measure because there are no data on the incidence of patient dumping before its enactment. The only measure of current incidence, that is, the number of confirmed violations, is also imprecise.
Many hospital administrators and physicians with whom GAO spoke said that the implementation of EMTALA adversely affects the efficiency and types of services provided in emergency departments and results in additional costs. Hospitals and physicians also expressed uncertainty to GAO about the extent of their responsibilities. For example, they have questions about how EMTALA applies to certain on-campus and off-campus hospital departments, known as provider-based facilities. It was asked whether walk-in patients could supplant scheduled patients by claiming their conditions are emergencies.
The extent to which providers are obligated under EMTALA to render follow-up care to emergency department patients was also discussed. The erroneous belief has spread that EMTALA obligates full treatment all the way to cure. This is not so, according to CMS. Hospitals’ obligations end once the patient is “stable for transfer.”
CMS officials told the GAO that they were aware of the difficulty providers have encountered in implementing some aspects of EMTALA and that it plans to provide more guidance and re-establish an advisory group of EMTALA stakeholders.
Few Violations Found
The report illustrates that the numbers of EMTALA violations and fines have been relatively small, and hospital’s Medicare provider agreements have rarely been terminated. Since 1995, CMS regional offices have directed state survey agencies to investigate about 400 hospitals per year and have cited about half of them for EMTALA violations. The numbers of investigations and proportion of confirmed violations vary among regions. CMS is taking steps to increase consistency among regions, which could assist providers in their efforts to comply with EMTALA.
From 1995 through 2000, the OIG imposed fines totaling over $5.6 million on 194 hospitals and 19 physicians. The majority of hospital fines were $25,000 or less. The total number of physicians ever fined by the OIG for EMTALA violations is 28. EMTALA has resulted in only four hospital exclusions.
The study comes as the American Medical Association (AMA) drafts a proposal to stop CMS from expanding the law to provider-based facilities. AMA wants the law to apply only to hospital emergency departments, and it wants Medicare and private insurers to pay for the screening and stabilizing of patients required by EMTALA. Adding to industry concerns, the U.S. 9thCircuit Court of Appeals ruled last January that EMTALA applies to non-hospital ambulances still en route to a facility. The court said a patient who died in an ambulance headed for Queen’s Medical Center in Honolulu showed up, for the purposes of the law, at the emergency department when the paramedics discussed the patient with a Queen’s emergency physician by radio and was diverted before arriving at the facility.
Neurosurgeons should be aware that without much pressure from GAO, CMS seems less likely to satisfy the requests of hospitals and physicians for negotiated rulemaking to subdue EMTALA. Medicare Compliance Alert (July 9, 2001) reports that a CMS spokesperson says Administrator Tom Scully will review the issues before the agency convenes an advisory committee on EMTALA. Stay tuned.
John A. Kusske, MD, is former Chair of the AANS Managed Care Advisory Committee.