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Cobra Laws And EMTALA
Definition/Introduction
In 1985, the United States Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA), which encompasses many regulations governing health insurance programs. This act encompasses mandates on private pension plans, disability insurance, group health plans, and emergency medical treatment. The focus of this topic is on the Emergency Medical Treatment and Active Labor Act (EMTALA).[1]
Congress enacted EMTALA in 1986, which guarantees nondiscriminatory access to emergency medical care.[2] EMTALA requires Medicare-participating hospitals to provide a medical screening examination (MSE) to anyone seeking treatment for an emergency medical condition (EMC), regardless of citizenship, legal status, or ability to pay. Hospitals and physicians may not transfer or discharge patients requiring emergent treatment or MSE except with stabilization or informed patient consent, or when the patient's condition requires transfer to an institution better prepared or equipped to provide treatment.[1] In 1989, an amendment to this bill was passed, stating that hospitals were also prohibited from delaying care to inquire about patients' ability to pay or proof of insurance.[3]
EMC is listed as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”[4][5] This definition encompasses a wide breadth of pathology. Another important caveat is that EMTALA applies to any area of a hospital campus, not only the emergency department.[6] COBRA and EMTALA laws are enforced by the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS).[7][8]
Issues of Concern
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Issues of Concern
The primary issue with the COBRA and EMTALA laws is that their terminology is vague and therefore open to interpretation.[3] The most commonly cited reason for an EMTALA violation is the inappropriate use of MSE.[1] Medical screening examinations may vary among practitioners and may be performed by nonphysicians, such as nurse practitioners or physician assistants. Various courts have accepted different meanings of MSE.[3] CMS has provided a worksheet that asks investigators about the MSE, which can range from a focused, often brief history and physical examination to a lengthy examination involving laboratory tests, diagnostic imaging, consultations, and procedures.[1] The failure of Congress to define MSE has led to more lawsuits than any other aspect of EMTALA.
HMOs and similar insurance programs are often not held liable for these violations, even as they gatekeep the care their clients receive. Although insurance programs are not penalized or required to pay for this service, physicians and hospitals do not receive compensation for treating uninsured and underinsured patients.[1] Retrospective analysis of medical screening examinations places the burden of violations on physicians. The fine for EMTALA violations ranges from $50,000 to $50,000 and is not covered by physician malpractice insurance.[3] A study conducted in California demonstrated a 6-year decline in on-call physician responsiveness. Physicians who responded to this survey reported that the insurance status of their patient population was a reason for avoiding taking the call, and this proportion increased from 42% to 80% over the 6-year study period. This paper also highlighted that emergency departments serving predominantly uninsured patients were less likely to have access to specialists.[9] This situation worsened in 2003, when EMTALA updates mandated that on-call physician panels need not include physicians from every specialty, only those that met the community's needs; as a result, subspecialists are rarely part of on-call physician panels.[1]
Of all investigations conducted by CMS, 40% involved violations, but only 3% resulted in fines.[1] The majority of recent violations involved hospitals and were related to patient dumping due to lack of insurance. Uninsured patients are more likely to experience interhospital transfer.[10] The violations against individual physicians were most commonly directed at specialists who refused to come in to evaluate emergency department patients. A single emergency medicine physician, from 2002 to 2015, violated EMTALA.[11]
About 20% of EMTALA violations settlements between 2002 and 2018 included psychiatric emergencies.[12] Due to the nature of mental illness and the lack of facilities at many hospitals to adequately treat these conditions, there is a high number of transfers from emergency departments to facilities that are better equipped. These facilities often screen patients for insurance coverage and ability to pay and deny transfers, which constitutes a clear EMTALA violation.[13] Patients who need psychiatric care are often subjected to long delays in care while waiting for an appropriate facility, which increases hospital mortality and length of stay.[14]
Clinical Significance
EMTALA and COBRA laws prevent "patient dumping," which is a form of economic discrimination where uninsured patients do not receive treatment and transfer to public institutions or are discharged because of the high anticipated costs of their emergency diagnoses or treatments.[1] Before enactment, patient dumping was a significant issue in emergency medicine. There were cases of patients being turned away from hospitals or transferred without stabilization, resulting in poor outcomes.[15] Patient dumping still occurs today, but at a far lower rate than before enactment.[16] A 1988 study found that 91% of patients transferred to another emergency department were transferred due to an inability to pay or lack of insurance.[17] Currently, the rate of patient dumping is estimated to be 1.7 violations per 1,000,000 emergency department visits.[8][18] It is difficult to determine an accurate rate before EMTALA's enactment, as there was no monitoring of such violations at that time.
EMTALA has often been cited as a major contributor to emergency department overcrowding and costs.[19] Overcrowding is due to a lack of alternatives for diverting patients who need non-emergent medical care but present to the emergency department, believing they will receive some form of care.[3] EMTALA is an unfunded mandate that places a financial burden on hospitals and physicians. In 2013, emergency departments in the United States provided $50 billion of uncompensated care under EMTALA.[8] Unfortunately, EMTALA doesn't prevent uninsured patients from being billed after receiving care and can financially cripple patients who sought medical care.[8] Additionally, EMTALA does not provide primary care or ongoing health maintenance to the underinsured and uninsured. However, the existence of this law proves the desire for universal access to emergency care. While states do not provide insurance to travelers and undocumented immigrants, every person, regardless of legal status and citizenship, is covered under EMTALA for emergent care.[3] This fact emphasizes the US society's regard for urgent care and the belief that an individual's health is vital to community health.
Nursing, Allied Health, and Interprofessional Team Interventions
Physicians are often held solely accountable for providing an appropriate medical screening examination and accurate documentation. However, 20% of EMTALA violations are attributable to emergency department nurses; these violations can range from incorrect transfer documentation to innocuous advice on where to obtain faster care. While nurses cannot be held liable under EMTALA, they are held accountable under their states' Nurse Practice Act, and they can also be named in medical malpractice lawsuits.[20][21] Other hospital care staff, such as pharmacists and physical therapists, are unlikely to be the cause of EMTALA violations. However, all care staff should ensure that every patient receives appropriate care regardless of insurance status or ability to pay.
References
Zuabi N, Weiss LD, Langdorf MI. Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements. The western journal of emergency medicine. 2016 May:17(3):245-51. doi: 10.5811/westjem.2016.3.29705. Epub 2016 May 4 [PubMed PMID: 27330654]
Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proceedings (Baylor University. Medical Center). 2001 Oct:14(4):339-46 [PubMed PMID: 16369643]
. Ethics of emergency department triage: SAEM position statement. SAEM Ethics Committee (Society for Academic Emergency Medicine). Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1995 Nov:2(11):990-5 [PubMed PMID: 8536127]
Level 1 (high-level) evidenceSawyer NT. Why the EMTALA Mandate for Emergency Care Does not Equal Healthcare "Coverage". The western journal of emergency medicine. 2017 Jun:18(4):551-552. doi: 10.5811/westjem.2017.5.34826. Epub 2017 May 15 [PubMed PMID: 28611872]
. Interpretation of EMTALA in Medical Malpractice Litigation. Annals of emergency medicine. 2018 Oct:72(4):e53. doi: 10.1016/j.annemergmed.2018.07.030. Epub [PubMed PMID: 30236346]
Hyman DA, Studdert DM. Emergency Medical Treatment and Labor Act: what every physician should know about the federal antidumping law. Chest. 2015 Jun:147(6):1691-1696. doi: 10.1378/chest.14-2046. Epub [PubMed PMID: 26033130]
. Emergency care EMTALA. Implementation and enforcement issues. The Kansas nurse. 2002 Jan:77(1):7-9 [PubMed PMID: 16381380]
McKenna RM, Purtle J, Nelson KL, Roby DH, Regenstein M, Ortega AN. Examining EMTALA in the era of the patient protection and Affordable Care Act. AIMS public health. 2018:5(4):366-377. doi: 10.3934/publichealth.2018.4.366. Epub 2018 Oct 8 [PubMed PMID: 30631780]
Rudkin SE, Langdorf MI, Oman JA, Kahn CA, White H, Anderson CL. The worsening of ED on-call coverage in California: 6-year trend. The American journal of emergency medicine. 2009 Sep:27(7):785-91. doi: 10.1016/j.ajem.2008.06.012. Epub [PubMed PMID: 19683105]
Venkatesh AK, Chou SC, Li SX, Choi J, Ross JS, D'Onofrio G, Krumholz HM, Dharmarajan K. Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition. JAMA internal medicine. 2019 May 1:179(5):686-693. doi: 10.1001/jamainternmed.2019.0037. Epub [PubMed PMID: 30933243]
Terp S, Wang B, Raffetto B, Seabury SA, Menchine M. Individual Physician Penalties Resulting From Violation of Emergency Medical Treatment and Labor Act: A Review of Office of the Inspector General Patient Dumping Settlements, 2002-2015. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2017 Apr:24(4):442-446. doi: 10.1111/acem.13159. Epub 2017 Mar 17 [PubMed PMID: 28109011]
Terp S, Wang B, Burner E, Connor D, Seabury SA, Menchine M. Civil Monetary Penalties Resulting From Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2019 May:26(5):470-478. doi: 10.1111/acem.13710. Epub 2019 Apr 17 [PubMed PMID: 30994255]
Schmalz A, Sawyer NT. The EMTALA Loophole in Psychiatric Care. The western journal of emergency medicine. 2020 Jan 27:21(2):244-246. doi: 10.5811/westjem.2019.10.45332. Epub 2020 Jan 27 [PubMed PMID: 31999243]
Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2011 Dec:18(12):1324-9. doi: 10.1111/j.1553-2712.2011.01236.x. Epub [PubMed PMID: 22168198]
Level 2 (mid-level) evidenceBrown HL, Brown TB. EMTALA: The Evolution of Emergency Care in the United States. Journal of emergency nursing. 2019 Jul:45(4):411-414. doi: 10.1016/j.jen.2019.02.002. Epub 2019 Mar 20 [PubMed PMID: 30902349]
Rosenbaum S, Cartwright-Smith L, Hirsh J, Mehler PS. Case studies at Denver Health: 'patient dumping' in the emergency department despite EMTALA, the law that banned it. Health affairs (Project Hope). 2012 Aug:31(8):1749-56. doi: 10.1377/hlthaff.2012.0517. Epub [PubMed PMID: 22869653]
Level 3 (low-level) evidenceKellermann AL, Hackman BB. Emergency department patient 'dumping': an analysis of interhospital transfers to the Regional Medical Center at Memphis, Tennessee. American journal of public health. 1988 Oct:78(10):1287-92 [PubMed PMID: 3048125]
Terp S, Seabury SA, Arora S, Eads A, Lam CN, Menchine M. Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014. Annals of emergency medicine. 2017 Feb:69(2):155-162.e1. doi: 10.1016/j.annemergmed.2016.05.021. Epub 2016 Aug 2 [PubMed PMID: 27496388]
Monico E. Is EMTALA That Bad? The virtual mentor : VM. 2010 Jun 1:12(6):471-5. doi: 10.1001/virtualmentor.2010.12.6.hlaw1-1006. Epub 2010 Jun 1 [PubMed PMID: 23158449]
Tammelleo AD. Can a nurse be individually liable for violating EMTALA? Case in point: Repp v. Anadarko Mun. Hosp. 43 F. 3d 519--OK (1994). The Regan report on nursing law. 1995 Mar:35(10):4 [PubMed PMID: 7724795]
Level 3 (low-level) evidenceTammelleo AD. Nurse's role in hospital compliance with EMTALA. The Regan report on nursing law. 1995 Nov:36(6):1 [PubMed PMID: 8552754]
Level 3 (low-level) evidence