Emtala

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UTLonghorns

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I admit I know very little to nothing about the field of Emergency Medicine. However, I was scanning through this forum to learn more and read about EMTALA. I don't know very much about it, but I did see several attendings give estimates of the money they have lost from it. The figures seemed pretty significant at $100k-$200k.

I was just wondering out of pure curiosity if any physician has ever gone to court over this. "Involuntary servitude is a United States legal and constitutional term for a person laboring against that person's will to benefit another, under some form of coercion other than the worker's financial needs." Is this not exactly would EMTALA does? Seems a pissed off doctor would have a pretty good case (correct me if I don't understand the subtleties of the law).

Disclaimer: I am not saying I would personally go to court if I was in a similar situation. I do believe doctors should help everyone. I just don't know if they should be forced to? The law just seems to blatantly go against the 13th amendment.

Further Disclaimer: I know I am just a pre-med. I am just curious, that is all.
 
I would imagine one could choose not to pay their fine and give up their license.

A few tidbits..

http://www.kevinmd.com/blog/2011/03/challenge-constitutionality-emtala.html

From another website.
The regulations also provide that a hospital found to be in violation may have its provider agreement revoked. This, of course, is likely to be a much more significant potential sanction, and this "Medicare death penalty" provides the biggest incentive to hospitals to accept the positions adopted by CMS in its enforcement activities.
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can_of_worms_ahead.jpg
 
UTLonghorns said:
correct me if I don't understand the subtleties of the law).
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There are no subtleties of the law that you are missing. It is an unfunded mandate, a hidden tax on doctors, mostly emergency physicians. The state of Washington recently granted itself the right to pick and choose which patients they are going to help. Doctors are denied that right. Look to the federal government to follow suite soon. Doctors are easy to push around from a legislative perspective. It seems compassionate to the poor, and people really don't care about the rights of rich doctors. Just like CEOs and corporations, we are vilified as evil and profit-seeking. The fact that the entire planet is "profit-seeking" never enters into the discussion.
 
EMTALA is a huge issue in medicine in general although many outside EM don't fully appreciate it.

Here is a thread on EMTALA from the FAQ which has lots of good info.

It's not really a subtlety that you missed but I can play devil's advocate for a minute and explain the counter argument to the "we shouldn't be forced to work for free" assertion. The government's position is that you are not being forced to endure servitude. Their assertion is that we are choosing to abide by the unfunded mandates of EMTALA by electing to participate in the Medicare and Medicaid programs. They would suggest that we could be free of EMTALA if we would just renounce our CMS participation and find EDs/hospitals to work in that are similarly outside the CMS program. That is completely unrealistic but that's their argument.
 
Okay, I did not realize you could opt out of the mandate. Thank you for the information.

Do the attendings out there think people without insurance would go unhelped without the mandate? I would like to believe doctors would help the people who truly needed it without a mandate forcing them too. Do you think this is realistic? Then people would not be able to take advantage of the system when they do not truly have an emergency and more time could be spent with other patients.

Is there anything physicians can do to seriously fight back against all the mandates?
 
so if my understanding is right, this new health care which will provide insurance for everyone should take care of the problem of EMPs providing ~$140K worth of charity work right?
 
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otacon88 said:
so if my understanding is right, this new health care which will provide insurance for everyone should take care of the problem of EMPs providing ~$140K worth of charity work right?
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No, because most of the "newly insured" will be Medicaid patients, which reimburses pennies for medical care at far below the cost of delivery. Medicaid might as well be charity care.
 
UTLonghorns said:
Do the attendings out there think people without insurance would go unhelped without the mandate?
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EMTALA was passed precisely because people were going without such care.

I think the rational approach would be to join every other industrialized nation in having universal healthcare, and then this wouldn't be a problem because there would be no uninsured patients.

Alternatively we can go with the far right's suggestion of just letting the uninsured die, but I think the market for emergency medicine will shrink considerably if we get rid of EMTALA, Medicare, and Medicaid.
 
pseudoknot said:
EMTALA was passed precisely because people were going without such care.

I think the rational approach would be to join every other industrialized nation in having universal healthcare, and then this wouldn't be a problem because there would be no uninsured patients.

Alternatively we can go with the far right's suggestion of just letting the uninsured die, but I think the market for emergency medicine will shrink considerably if we get rid of EMTALA, Medicare, and Medicaid.
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Of course that's the only RATIONAL way to do things. Because things are going so peachy-keen in Europe right now (BTW just got back from Greece last month and it's a complete mess!).

Not that the U.S. is any better financially, while Europe fritters away their money on social programs, we flush ours down the toilet in wars, stimulus and "cash for clunkers".
 
GeneralVeers said:
Of course that's the only RATIONAL way to do things. Because things are going so peachy-keen in Europe right now (BTW just got back from Greece last month and it's a complete mess!).

Not that the U.S. is any better financially, while Europe fritters away their money on social programs, we flush ours down the toilet in wars, stimulus and "cash for clunkers".
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Right, there is a global economic downturn. However, we spend VASTLY more on healthcare than those other systems. Just our government healthcare spending per capita is as much as places that have universal healthcare…not even counting the private system. And we have mostly poorer outcomes. But I don't think policy will be influenced by facts in the foreseeable future.
 
Oh my... We could go on and on about universal healthcare. Lets not dive into that though it is a natural consequence of the EMTALA discussion.

I think if an EP wants universal healthcare for their patients they should go work in the VA LSUs. You can get a taste of what that would be like.

I wont dive further as I have been heavily embroiled in political discussions with others and my desire to add to it here is nil.

On another note for an EP to opt out of CMS is impossible since we dont own or run EDs. You could work in urgent cares and watch your skills leave you.
 
pseudoknot said:
And we have mostly poorer outcomes.
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I disagree. We have worse outcomes on a few things because we allow it. Infant mortality is high because lots of women don't go get the free healthcare they are provided under the law. As a group we are one of the fattest nations. We also have a much broader genetic basis so we have wide swings between blacks, whites, etc when it comes to mortality.

Compare our 10 year cancer survival rates to other countries. Transplants. You name it, if it is cutting edge, it is here. Not to say other countries don't have good healthcare systems, but remember, their doctors are paid less and go to school for free. I can foresee us getting paid less, but I don't think we will ever go to school for free in this country.

The average American living to age 40 has a longer lifespan than almost any country. It's the crap that gets us before that, which can't be solved with any government mandate beyond boots on the neck.
 
Dr.McNinja said:
Infant mortality is high because lots of women don't go get the free healthcare they are provided under the law.
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Also, we try to save the preemies that most - virtually all - other countries just let die, and they don't even count them against their numbers (like infants that die at 1wk or less of life - term or not - like they never even existed).
 
Dr.McNinja said:
I disagree. We have worse outcomes on a few things because we allow it. Infant mortality is high because lots of women don't go get the free healthcare they are provided under the law. As a group we are one of the fattest nations. We also have a much broader genetic basis so we have wide swings between blacks, whites, etc when it comes to mortality.

Compare our 10 year cancer survival rates to other countries. Transplants. You name it, if it is cutting edge, it is here. Not to say other countries don't have good healthcare systems, but remember, their doctors are paid less and go to school for free. I can foresee us getting paid less, but I don't think we will ever go to school for free in this country.

The average American living to age 40 has a longer lifespan than almost any country. It's the crap that gets us before that, which can't be solved with any government mandate beyond boots on the neck.
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Disagree with the part about infant mortality. The "higher" mortality is all based in part upon what qualifies as infant mortality. In Europe they DO NOT RESUSCITATE tiny infants with little chance of meaningful survival. Therefore they are not included in the stats for infant mortality. In America, since religious crazies control most social policy we resuscitate infants who are much more premature, only to watch them linger and die in the NICU shortly thereafter. These are included in the "infant mortality" rolls as they are technically born alive but die afterwards.
 
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GeneralVeers said:
Disagree with the part about infant mortality. The "higher" mortality is all based in part upon what qualifies as infant mortality. In Europe they DO NOT RESUSCITATE tiny infants with little chance of meaningful survival. Therefore they are not included in the stats for infant mortality. In America, since religious crazies control most social policy we resuscitate infants who are much more premature, only to watch them linger and die in the NICU shortly thereafter. These are included in the "infant mortality" rolls as they are technically born alive but die afterwards.
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Umm...yeah, I said exactly that directly above you 2 1/2 hours before you. I guess I don't rate.
 
GeneralVeers said:
Disagree with the part about infant mortality. The "higher" mortality is all based in part upon what qualifies as infant mortality. In Europe they DO NOT RESUSCITATE tiny infants with little chance of meaningful survival. Therefore they are not included in the stats for infant mortality. In America, since religious crazies control most social policy we resuscitate infants who are much more premature, only to watch them linger and die in the NICU shortly thereafter. These are included in the "infant mortality" rolls as they are technically born alive but die afterwards.
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Absolutely true. Add to this that we count any premature birth with a heart rate as a live birth. When I was covering nursery I'd get called to declare an 18 week fetus that had delivered. No chance of survival and no possible interventions, yet it counted as a 'live' birth because there was a heart rate.

The other issue is that our rate of premature births (and we will resuscitate a 22 weeker at this point) is high compared to other countries. You can say this is due to lack of access, however I routinely see moms who qualify for free prenatal care but who never bothered to get it. Or they decided to do cocaine. And many don't care. A few states (most? I don't know) will cover the expenses of any infant born less than 1000g birth weight. I've heard people actually say 'oh don't worry, if you go into labor early it will be covered.'
 
Prior to EMTALA, it was not uncommon for ED patients to undergo a walletectomy or even be social-economic-racial profiled prior to receiving care or being dumped to other facilities.

EMTALA may not be perfect (and it ain't), but the alternative may not be much better..... especially if you or your love ones are the patient being profiled.
 
StevieStud said:
Prior to EMTALA, it was not uncommon for ED patients to undergo a walletectomy or even be social-economic-racial profiled prior to receiving care or being dumped to other facilities.

EMTALA may not be perfect (and it ain't), but the alternative may not be much better..... especially if you or your love ones are the patient being profiled.
Click to expand...

COBRA existed then.
 
StevieStud said:
Prior to EMTALA, it was not uncommon for ED patients to undergo a walletectomy or even be social-economic-racial profiled prior to receiving care or being dumped to other facilities.

EMTALA may not be perfect (and it ain't), but the alternative may not be much better..... especially if you or your love ones are the patient being profiled.
Click to expand...

EMTALA would be completely workable, if not for medical liability issues. Ideally every patient would get a medical screening exam by a triage nurse (there's nothing about the law that says a doctor has to do it), then if they had no "emergency" as determined by the triage nurse they'd go for wallet biopsy, and treatment by the ED physician if they had insurance or agreed to pay out of pocket.

The problem arises in that if that nurse screws up and sends an emergency home, the hospital and physician on duty will get sued. Therefore the "medical screening exam", ends up being a complete workup, diagnosis, and treatment at most facilities, which effectively amounts to free care and indentured servitude.
 
GeneralVeers said:
EMTALA would be completely workable, if not for medical liability issues. Ideally every patient would get a medical screening exam by a triage nurse (there's nothing about the law that says a doctor has to do it), then if they had no "emergency" as determined by the triage nurse they'd go for wallet biopsy, and treatment by the ED physician if they had insurance or agreed to pay out of pocket.

The problem arises in that if that nurse screws up and sends an emergency home, the hospital and physician on duty will get sued. Therefore the "medical screening exam", ends up being a complete workup, diagnosis, and treatment at most facilities, which effectively amounts to free care and indentured servitude.
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👍👍👍
 
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StevieStud said:
Prior to EMTALA, it was not uncommon for ED patients to undergo a walletectomy or even be social-economic-racial profiled prior to receiving care or being dumped to other facilities.
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How were they profiled? They are saying, "Listen, we will gladly treat you, but you will get billed by us and sent to collections. Down the road is a county hospital that specializes in providing indigent care. You will probably get cheaper care there. Do you want to stay here, or risk the transfer? The decision is yours."

EMTALA, like all bureaucratic mandates, has unintended consequences that have just as many adverse side effects as the problems they are trying to solve.

Two must read books for this discussion are Economic Facts and Fallacies and The Death of Common Sense.

I discussed a couple of scenarios in the second post of the following thread:

http://forums.studentdoctor.net/showthread.php?t=752785

Recently, I ran into another scenario, where doing what is right for the patient is interfered with by EMTALA. Our hospital is just a few blocks from another hospital. Frequently, *****s come to our hospital in labor with a certain type of insurance that doesn't pay for labor at our hospital but does at the hospital down the road. Our administration is so paranoid of getting an EMTALA violation, that they recommend the patient get checked in, ruled out for imminent labor and incur a massive bill before the question about insurance is brought up. If the patient knew that they were literally 2 minutes from thousands less in bills, they would be able to make the decision with eyes wide open. This is not a hospital 30 minutes away were they are likely to drop the kid on the way. If the kid is not crowning, they should be given the opportunity to avoid a massive bill.
 
Jarabacoa said:
Recently, I ran into another scenario, where doing what is right for the patient is interfered with by EMTALA. Our hospital is just a few blocks from another hospital. Frequently, *****s come to our hospital in labor with a certain type of insurance that doesn't pay for labor at our hospital but does at the hospital down the road. Our administration is so paranoid of getting an EMTALA violation, that they recommend the patient get checked in, ruled out for imminent labor and incur a massive bill before the question about insurance is brought up. If the patient knew that they were literally 2 minutes from thousands less in bills, they would be able to make the decision with eyes wide open. This is not a hospital 30 minutes away were they are likely to drop the kid on the way. If the kid is not crowning, they should be given the opportunity to avoid a massive bill.
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We have the same problem at one hospital that just closed its L&D floor. We now have no L&D or OB/GYN. Rather than post this outside the hospital, or tell patients this up front, we are forced to treat every pregnant/gyn patient and transfer them after a workup. This causes their bill to essentially double as they get a 2nd bill from the other hospital, not to mention the cost of ambulance transport.
 
Jarabacoa said:
How were they profiled? They are saying, "Listen, we will gladly treat you, but you will get billed by us and sent to collections. Down the road is a county hospital that specializes in providing indigent care. You will probably get cheaper care there. Do you want to stay here, or risk the transfer? The decision is yours."
Click to expand...


Yep.

Typically it was the triage nurse who was trying to "look out" for the needs of the patient.

The usual patter was something along the line of "honey, have you met your deductible..... you know you can go over to City and they will see you right away and you won't have to worry about paying the bill ".

Personally, back in my college days, I was offered a bus pass if I would take myself cross town to the university hospital for a simple laceration. I had an after school job doing some landscaping and was covered in dirt and worse and guess the angel of mercy was confused as to my status. Don't worry, all was forgiven after my insurance card was found in my wallet.
 
Tired said:
There are two small roadblocks to what you discuss:

(1) First, triage is a separate process from an MSE under the law. Performing a triage evaluation and having that serve as an MSE is a violation of the law.
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You can easily develop an "MSE process" whereby you specifically meet the requirements on EMTALA. The law is rather vague about what is required, and who can do the exam.

(2) Nurses can perform medical screening exams, but only if they have been certified to do so in the medical bylaws of the facility. Generally these "certifications" have to identify qualified non-physicians to do the MSE by name. You won't get away with "all nurses can perform an MSE." The same rule applies to APRNs.
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Again, EMTALA is vague about the precise training required. If you developa training process whereby nurses are trained to do an MSE you can meet the requirements.
 
Most facilities that have 24hr/day EM physician coverage will be extremely reluctant to delegate the MSE to non-physicians. If someone is screened out that has an emergent condition than the hospital is going to be writing a check, guaranteed. If a physician screens out a patient with an emergent condition, the hospital has at least some chance of weaseling out of it.

What I consider really abusive is using EMTALA as a back door for suing for bad outcomes because the argument that delay in obtaining an MSE = denial of a pt's right to an MSE. Combine that with the pure fiction of guidelines for how long it is acceptable for a patient to wait based on triage level, and you have an ugly scenario.
 
Arcan57 said:
Most facilities that have 24hr/day EM physician coverage will be extremely reluctant to delegate the MSE to non-physicians. If someone is screened out that has an emergent condition than the hospital is going to be writing a check, guaranteed. If a physician screens out a patient with an emergent condition, the hospital has at least some chance of weaseling out of it.
Click to expand...

That is exactly my point. The medical liability climate essentially makes EMTALA an unfunded mandate to provide free care to everyone.

What I consider really abusive is using EMTALA as a back door for suing for bad outcomes because the argument that delay in obtaining an MSE = denial of a pt's right to an MSE. Combine that with the pure fiction of guidelines for how long it is acceptable for a patient to wait based on triage level, and you have an ugly scenario.
Click to expand...

And if you think that is bad, just wait until we make healthcare a "right" under law as some on the left propose. Let the litigation commence!
 
EMTALA stacks the deck so heavily against the physician in the patient-physician relationship; it's just plain wrong. To require you to provide your services, free of charge, 24 hours per day, 365 days per year, yet offer and guarantee essentially no payment or pennies on the dollar at best, yet preserve the "customers" "right" to sue you for millions of dollars, whether you did anything wrong or not.... it’s just plain wrong. Most lay people have no idea how many people abuse the system and come to the ED for anything but emergencies. Dedicating a portion of your services to charity is one thing. Requiring, under the full force and strength of the law with no compensation or protection from liability is another. Does the government require, under the force of law, with threats of $50,000 fines or worse, require plastics surgeons or dermatologists to give an unlimited amount of free care without any payment? Do they require lawyers and corporate execs to do this?

ER physicians are not the ones who made EMTALA necessary. It was administrators of for-profit hospitals who created policies to transfer ambulance traffic of uninsured patients to not-for-profit hospitals. Yet, you are forced to suffer the consequences. Similarly, in an attempt to save more money for themselves at your expense, for-profit hospitals may ask you to work a loophole around EMTALA. "Medically screen" a patient and demand payment up front for those you deem "non-emergencies". Follow this: you spend your time screening the patient (incur liability), you deem them "non-emergent", they're asked for payment, they don't have the money and they go away. The system worked the way it's supposed to, right? Clearly, not for the patient. Clearly yes, for the hospital. How about for the ER physician? You donate your time seeing the patient, doing the right thing; the patient goes away and sees their PCP next week for their non-emergency (which they don't do, instead they go to the next ED down the street, not-for-profit, that has no such policy). It's great until you get sued for one of these patients who you were required to see, were not allowed to bill, and evaluated (but didn't treat) for free, for what purpose? To benefit the patient? No. To save money for the hospital? Yes. All the while, you've spent time away from actually treating and helping patients and generating RVUs ($) for yourself, while incurring all the liability as you would if you were paid. Then for salt in the wounds, they send the patient a Press Gainey survey to fill out.

It would be one thing if the government paid you (fair market value) for your services in these cases, offered some sort of malpractice protection, or at a bare minimum allowed you to deduct these huge amounts of lost payments from your taxes. They let hospitals deduct these losses as "charity". Why don't they let ER doctors do this? As physicians, and especially EM physicians you have tremendous power and you don't even know it, or you're afraid to use it. Use that power, honestly and ethically for the benefit of your patients and yourselves. Patients will not benefit if ER physicians leave the specialty or refuse to enter it, will they? It's not right that for saving a life you get paid 1/10th of what a plastic does for a nose job? It's not wrongfor you to be paid for what you do.
I thank God every day I am no longer governed by EMTALA. It's renewed my faith, energy and attitude towards doctoring.
 
My current job actually will pay us for performing an MSE and determining the patient is non-emergent. It falls in-between a level I and a level II visit. Which is better than nothing. My previous job tried this, but since we were doing all the same work and guaranteeing we wouldn't get paid nobody got screened out.
 
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Birdstrike said:
EMTALA stacks the deck so heavily against the physician in the patient-physician relationship; it's just plain wrong. To require you to provide your services, free of charge, 24 hours per day, 365 days per year, yet offer and guarantee essentially no payment or pennies on the dollar at best, yet preserve the "customers" "right" to sue you for millions of dollars, whether you did anything wrong or not.... it’s just plain wrong.

It would be one thing if the government paid you (fair market value) for your services in these cases, offered some sort of malpractice protection, or at a bare minimum allowed you to deduct these huge amounts of lost payments from your taxes. They let hospitals deduct these losses as "charity". Why don't they let ER doctors do this? As physicians, and especially EM physicians you have tremendous power and you don't even know it, or you're afraid to use it. Use that power, honestly and ethically for the benefit of your patients and yourselves.
Click to expand...

Spot on.
 
Birdstrike said:
EMTALA stacks the deck so heavily against the physician in the patient-physician relationship; it's just plain wrong. To require you to provide your services, free of charge, 24 hours per day, 365 days per year, yet offer and guarantee essentially no payment or pennies on the dollar at best, yet preserve the "customers" "right" to sue you for millions of dollars, whether you did anything wrong or not.... it’s just plain wrong. Most lay people have no idea how many people abuse the system and come to the ED for anything but emergencies. Dedicating a portion of your services to charity is one thing. Requiring, under the full force and strength of the law with no compensation or protection from liability is another. Does the government require, under the force of law, with threats of $50,000 fines or worse, require plastics surgeons or dermatologists to give an unlimited amount of free care without any payment? Do they require lawyers and corporate execs to do this?

ER physicians are not the ones who made EMTALA necessary. It was administrators of for-profit hospitals who created policies to transfer ambulance traffic of uninsured patients to not-for-profit hospitals. Yet, you are forced to suffer the consequences. Similarly, in an attempt to save more money for themselves at your expense, for-profit hospitals may ask you to work a loophole around EMTALA. "Medically screen" a patient and demand payment up front for those you deem "non-emergencies". Follow this: you spend your time screening the patient (incur liability), you deem them "non-emergent", they're asked for payment, they don't have the money and they go away. The system worked the way it's supposed to, right? Clearly, not for the patient. Clearly yes, for the hospital. How about for the ER physician? You donate your time seeing the patient, doing the right thing; the patient goes away and sees their PCP next week for their non-emergency (which they don't do, instead they go to the next ED down the street, not-for-profit, that has no such policy). It's great until you get sued for one of these patients who you were required to see, were not allowed to bill, and evaluated (but didn't treat) for free, for what purpose? To benefit the patient? No. To save money for the hospital? Yes. All the while, you've spent time away from actually treating and helping patients and generating RVUs ($) for yourself, while incurring all the liability as you would if you were paid. Then for salt in the wounds, they send the patient a Press Gainey survey to fill out.

It would be one thing if the government paid you (fair market value) for your services in these cases, offered some sort of malpractice protection, or at a bare minimum allowed you to deduct these huge amounts of lost payments from your taxes. They let hospitals deduct these losses as "charity". Why don't they let ER doctors do this? As physicians, and especially EM physicians you have tremendous power and you don't even know it, or you're afraid to use it. Use that power, honestly and ethically for the benefit of your patients and yourselves. Patients will not benefit if ER physicians leave the specialty or refuse to enter it, will they? It's not right that for saving a life you get paid 1/10th of what a plastic does for a nose job? It's not wrongfor you to be paid for what you do.
I thank God every day I am no longer governed by EMTALA. It's renewed my faith, energy and attitude towards doctoring.
Click to expand...

As disheartening as it is for students and residents to read this I have to agree completely. I am sorry to say it but this is the state of our specialty. We are victims of the business practices of the past generation.

Arcan57 said:
My current job actually will pay us for performing an MSE and determining the patient is non-emergent. It falls in-between a level I and a level II visit. Which is better than nothing. My previous job tried this, but since we were doing all the same work and guaranteeing we wouldn't get paid nobody got screened out.
Click to expand...

In my situation we get "paid" to do these screenings but it's really a redistribution of money that was already ours, i.e. we compensate docs for the screenings by diverting money that would have gone to productivity bonuses. The hospitals would never consider subsidizing this. And maybe they shouldn't. It's one thing if we pay ourselves to perform a service that we have to do to maintain a contract. It's another if the hospital subsidizes us to turn away the no pays. It's a tough spot.
 
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