28 Sep Article:?Examining EMTALA in the era of the patient protection and Affordable Care Ac
Review this document in preparation for your journal assignment:
Article: Examining EMTALA in the era of the patient protection and Affordable Care Act
EMTALA was designed to protect patients from being turned away when searching for emergency medical care.
For this assignment, address the following questions.
- What unanticipated consequences have occurred from this legislation?
- What were some of the unanticipated benefits?
- As chief executive officer (CEO) of a health system, what measures would you implement in your organization to stop these issues from negatively impacting your organization’s productivity?
Your assignment should be a minimum of two pages in length and should include a title page and reference page (title and reference pages do not count toward the minimum word requirement).
To support your discussion, you should include at least two sources. All sources used must be referenced; paraphrased and quoted material must have accompanying citations. References and citations must be provided using APA Style.
AIMS Public Health Volume 5, Issue 4, 366-377.
AIMS Public Health, 5(4): 366–377
DOI: 10.3934/publichealth.2018.4.366
Received: 24 May 2018
Accepted: 21 September 2018
Published: 08 October 2018
http://www.aimspress.com/journal/aimsph
Research article
Examining EMTALA in the era of the patient protection and
Affordable Care Act
Ryan M. McKenna 1, *, Jonathan Purtle
2 , Katherine L. Nelson
3 , Dylan H. Roby
4 ,
Marsha Regenstein 5 and Alexander N. Ortega
6
1 Department of Health Management and Policy, Dornsife School of Public Health, Drexel
University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 2 Department of Health Management and Policy, Dornsife School of Public Health, Drexel
University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 3 Department of Health Management and Policy, Dornsife School of Public Health, Drexel
University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 4 Department of Health Services Administration, School of Public Health, University of Maryland,
4200 Valley Dr # 2242, College Park, MD 20742, USA 5 Department of Health Policy and Management, Milken Institute School of Public Health, George
Washington University, 950 New Hampshire Ave NW, Washington, DC 20052, USA 6 Department of Health Management and Policy, Dornsife School of Public Health, Drexel
University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA
* Correspondence: Email: [email protected]; Tel: +2673596188.
Abstract: Background: Little is known regarding the characteristics of hospitals that violate the
Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by
examining EMTALA settlements from violating hospitals and places these descriptive results within
the current debate surrounding the Patient Protection and Affordable Care Act (ACA). Methods: We
conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty
settlements from 2002–2015 and created a dataset describing the nature of each settlement. These
data were then matched with Thomson Healthcare hospital data. We then present descriptive
statistics of each settlement over time, plot settlements by type of violation, and provide the
geographic distribution of settlements. Results: Settlements resulting from EMTALA violations
decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting
from violations most commonly occurred for failure to screen and failure to stabilize patients in need
367
AIMS Public Health Volume 5, Issue 4, 366-377.
of emergency care. Settlements were most common in hospitals in the South (48%) and in urban
areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%)
were located in the South or in urban areas (65%). Violating hospitals incurred annual
settlements of $31,734 on average, for a total $5,299,500 over the study period. Conclusions:
EMTALA settlements declined prior to and after the implementation of the ACA and were most
common in the South and in urban areas. EMTALA’s status as an unfunded mandate, scheduled cuts
to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals
and could result in an increase of EMTALA violations. Policymakers should be cognizant of the
interplay between the ACA and complementary laws, such as EMTALA, when considering changes
to the law.
Keywords: health policy; Affordable Care Act; emergency medicine; health reform; insurance reform
Abbreviations: ACA: Patient Protection and Affordable Care Act; CBO: Congressional Budget
Office; CMS: Centers for Medicare and Medicaid Services; DSH: Disproportionate Share Hospital;
ED: Emergency Department; EMTALA: Emergency Medical Treatment and Active Labor Act; OIG:
Office of the Inspector General
1. Introduction
Since its passage in 1986, the EMTALA has been one of the most comprehensive laws granting
nondiscriminatory access to emergency medical care [22, 32]. EMTALA was originally conceived as
a policy to prevent ―patient dumping‖, the refusal of EDs to treat patients who could not pay for
treatment [22]. EMTALA mandates that a hospital must appropriately screen, stabilize, and, if
necessary, transfer a patient regardless of insurance status or ability to pay. If it is deemed necessary
that the patient needs to be transferred, they must be transferred to a facility with appropriate care
and the receiving facility must accept the patient [31].
Federal enforcement of EMTALA is managed by two agencies, CMS and OIG. EMTALA
investigations are initiated with a complaint being filed with one of the 10 regional CMS offices
and typically submitted by patients, hospitals, or ED staff [1]. If a violation is confirmed by CMS
field investigators, hospitals must submit a plan to correct deficiencies highlighted by CMS within
90 days [2]. Hospitals that fail to implement acceptable corrective actions risk termination of their
Medicare provider agreements, which could result in a significant financial loss and lead to the
closure of the facility. If the plan is accepted by CMS, the investigation ends; however, the OIG may
still levy punitive fines on hospitals and physicians’ offices. Fines have a maximum of $50,000 per
hospital and physician and are not covered by physician malpractice insurance.
Since EMTALA’s implementation, the rate of reported patient dumping has dropped substantially,
with recent estimates from 2005–2014 showing rates as low as 1.7 violations for every 1,000,000 ED
visits [27]. While these rates represent a sharp departure from previous highs in the 1980s, EMTALA
violations suffer from underreporting and hospitals still face compliance issues [12]. Additionally,
while EMTALA represents an important safety net for those without insurance coverage, it does not
guarantee free care to the patient and is not intended as a substitute for routine care. Under EMTALA,
368
AIMS Public Health Volume 5, Issue 4, 366-377.
patients cannot be denied emergency care based on inability to pay, but may still be billed after
receiving care. This could result in bad debt for both the consumer (i.e., bankruptcy) and the provider
(i.e., uncompensated care). EDs already provide more uncompensated care to the uninsured than
hospitals or outpatient clinics combined and nationally this amounted to approximately $50 billion in
2013 (HHS.gov 2015).
The insurance expansion provisions of the 2010 ACA lowered the uninsured rate for individuals
ages 18–64 years from a high of 18.4% in 2013 to 10.2% in 2016, a reduction of 45% [4]. While
findings of the ACA’s impact on ED utilization are mixed, some recent studies have shown that the
ACA is associated with improvements in access to usual sources of care other than the ED and
primary care utilization, especially for low-income groups and racial/ethnic minorities [3,15,25].
The expansion altered the payer-mix of many providers away from self-pay, which resulted in
improved charge capture, reductions in uncompensated care, and potentially served to lower rates
of patient dumping [7,8]. Thus, after the national implementation of the ACA in 2014, we would
expect to observe a decline in patient dumping and settlements arising from EMTALA violations.
Several proposals to repeal and replace the ACA were estimated by the CBO to reverse nearly all
of the gains in coverage attributable to the ACA [5,6,13]. Although those proposals ultimately
failed to become law during the summer of 2017 legislative session, there are still proposals being
circulated to reverse the ACA’s insurance expansion through administrative action and by reducing
Medicaid spending via the federal budget.
Hospitals serving large numbers of Medicaid and uninsured individuals are eligible for federal
DSH payments, to help offset the costs of uncompensated care. Since the insurance expansion has
likely worked to reduce the burden of uncompensated care, the ACA has built-in cuts to DSH
payments to help reduce expenditures. These scheduled reductions to DSH payments will place
greater strain on safety net hospitals. This increased strain could lead to patient dumping in order
to avoid the increased shortfalls in revenue. The impact of DSH payments cuts will be magnified in
Medicaid non-expansion states that have many low-income adults in the ―coverage gap‖ [9,18].
The uninsured low-income population are more likely than their privately insured counterparts to
use EDs and impose a risk of uncompensated care for systems [14,20].
In the face of reform efforts that would increase the number of uninsured patients and the
scheduled cuts to DSH payments, it is important to understand the current prevalence of EMTALA
violations and their distribution across the country. Despite its importance as a federal law
mandating the provision of emergency medicine, little empirical work has been published on
EMTALA violations and virtually none has examined the impact of the law within the context of
the ACA and current debates about health care and insurance reform [1,22,26,30].
This study adds to the current health reform debate by analyzing the content of all settled
EMTALA violations from the OIG between 2002–2015 and identifying the prevalence and
correlates of these cases. While settled fines do not constitute the universe of violations they are
one of the few publically available markers by which to measure EMTALA violations.
Additionally, while our findings are not causal in nature, we offer a descriptive analysis of these
settlements and discuss the implications of results within the broader context of the current health
care reform debate surrounding the ACA.
2. Methods
369
AIMS Public Health Volume 5, Issue 4, 366-377.
This study is a retrospective analysis of settled OIG civil monetary penalty settlements related
to EMTALA violations from the OIG. Not every complaint which generates an EMTALA
investigation results in a monetary settlement, thus we do not observe the entire universe of
EMTALA complaints, only settled violations (approximately 7.9% of all violations [32]). In the
event that a violation was found, CMS forwards the case to OIG, where the OIG decides if a
monetary fine is warranted. We rely on settled cases as there are few reliable sources of data to
assess patient dumping and cases settled by OIG have been used in prior work [30]. For brevity,
we hereby refer to settlements that resulted from EMTALA violations as ―settlements‖ in the
manuscript.
The OIG website provides a one paragraph description about every EMTALA settlement
since 2002. We conducted a content analysis of this information for all 191 settlements posted on
the OIG website through 2015. A coding instrument was created in Qualtrics, a web-based survey
tool, and each settlement was coded according to the nature of the violation and the characteristics
of the patients involved [19]. We coded each settlement according to the year it occurred, the total
dollar amount fined, the number of patients involved, and the type of violation that resulted in the
settlement (i.e., failure to provide appropriate screening, failure to accept transfer, failure to
provide appropriate transfer, failure to provide appropriate stabilization, or unknown). Settlements
that occurred but had an unclear cause in the OIG reports were coded as ―unknown‖ in our type of
violation measure.
Hospital financial and geographic data from Thomson Healthcare Profile of US Hospitals
were merged with the OIG EMTALA violation data by hospital name and address using Microsoft
Excel 2016 [27]. The Thomson data include each hospital’s unique Medicare ID, US Census
region (Midwest, Northeast, South, West), geographic status (urban, rural), DSH status, and
number of beds.
The merged dataset was imported into R [20] statistical software version 3.4.1 for analyses.
First, annual trends in EMTALA settlements were plotted and stratified by type of violation which
resulted in a settlement. Second, descriptive statistics were generated to describe hospital and
geographic characteristics of violating hospitals. Third, 2010 Census data were used to calculate
per-capita average fines at the state-level [30]. Results were plotted on a map of the US to visually
explore geographic heterogeneity in EMTALA settlements and fines.
3. Results
We identified 191 EMTALA settlement agreements, which resulted in settlements that
occurred between 2002–2015. A total of 24 hospitals could not be uniquely identified from the
settlement reports or had active data in the Thompson database and were excluded from the
analyses, for a total of 148 unique hospitals. After merging the settlements with the Thompson
data, we had a sample of 167 settlements with associated hospital characteristics, none of which
involved individual physicians.
Figure 1 shows annual trends in settled EMTALA violations from 2002–2015. The Figure is
right skewed, which reflects a decline in the overall number of EMTALA settlements that range
from a high of 46 in 2002 to a low of 6 in 2015, or a decline of 87%. Settlements did increase by
50% in 2013 relative to 2012, driven mostly by failure to appropriately screen. The shaded bar in
Figure 1 indicates the national implementation of the ACA in 2014, which corresponds with a
370
AIMS Public Health Volume 5, Issue 4, 366-377.
continued decline in overall settlements from 16 in 2014 to 6 in 2015. Throughout the 2002–2015
study period, the most common reason for a settlement was failure to appropriately screen
followed by failure to stabilize.
Figure 1. Settled EMTALA Violations by Type, Office of Inspector General 2002–2015.
General (OIG) ―patient dumping‖ settled violation case summaries from 2002–2015. These
violations reflect settled cases, not all alleged EMTALA violations. The shaded bar
represents the national implementation of the Patient Protection and Affordable Care Act.
Table 1 presents descriptive statistics of settled EMTALA settlements, as well as
characteristics of violating hospitals. Nearly half of the settlements (47.9%) occurred at hospitals
in the South, with the fewest settlements occurring in the Northeast (5.39%). Hospitals in urban
areas (74.3%) were more likely than hospitals in rural areas (25.7%) to incur a settlement.
Violating hospitals that had a settlement incurred an annual average fine of $31,734, for a total
$5,299,500 over the study period. No hospital in the sample had its Medicaid provider agreement
terminated as the result of an EMTALA settlement. Information on DSH status was unavailable in
the Thomson data for 70 hospitals in the sample. For the hospitals for which their DSH status
could be determined, sub analyses were conducted. Over a fifth of the hospitals (22.16%) had DSH
status, with 62% of these hospitals located in the South and 65% located in urban areas.
Figure 2 displays distribution of average fines at the state-level adjusted by each state’s
population size. With the exceptions of Vermont and Iowa, per-capita fines are concentrated in the
South and the Western US. As a robustness check, and to assess whether changes in the rate of
EMTALA settlements might have resulted from differences in enforcement arising from changes to
the OIG’s budget, we calculated inflation-adjusted OIG budgets in from 2007–2015. We found that
inflation-adjusted OIG budgets did not substantially decline over the 2007–2015 period and actually
reached their highest levels in 2015.
371
AIMS Public Health Volume 5, Issue 4, 366-377.
Table 1. Descriptive Statistics of Settled EMTALA Violations, Office of Inspector General 2002–2015.
2002
(27)
2003
(25)
2004
(17)
2005
(15)
2006
(11)
2007
(13)
2008
(8)
2009
(5)
2010
(7)
2011
(8)
2012
(6)
2013
(12)
2014
(10)
2015
(3)
Total
(167)
Region
Midwest 3.70
(1)
8.00
(2)
41.18
(7)
20.00
(3)
45.45
(5)
30.77
(4)
25.00
(2)
20.00
(1)
14.29
(1)
25.00
(2)
50.00
(3)
41.67
(5)
30.00
(3)
0.00
(0)
23.35
(39)
Northeast 0.0
(0)
8.00
(2)
5.88
(1)
6.67
(1)
9.09
(1)
0.00
(0)
0.00
(0)
20.00
(1)
0.00
(0)
0.00
(0)
16.67
(1)
0.00
(0)
20.00
(2)
0.00
(0)
5.39
(9)
South 48.15
(13)
52.00
(13)
41.18
(7)
46.67
(7)
27.27
(3)
38.46
(5)
62.50
(5)
40.00
(2)
71.43
(5)
62.50
(5)
33.33
(2)
58.33
(7)
40.00
(4)
66.67
(2)
47.90
(80)
West 48.15
(13)
32.00
(8)
11.76
(2)
26.67
(4)
18.18
(2)
30.77
(4)
12.50
(1)
20.00
(1)
14.29
(1)
12.50
(1)
0.00
(0)
0.00
(0)
10.00
(1)
33.33
(1)
23.35
(39)
Urban 66.67
(18)
76.00
(19)
58.82
(10)
80.00
(12)
81.82
(9)
84.62
(11)
75.00
(6)
100.00
(5)
100.00
(7)
75.00
(6)
66.67
(4)
66.67
(8)
70.00
(7)
66.67
(2)
74.25
(124)
Violations*
Screening 74.07
(20)
84.00
(25)
76.47
(13)
100.00
(15)
90.91
(10)
76.92
(10)
75.00
(6)
80.00
(4)
57.14
(4)
50.00
(4)
66.67
(4)
83.33
(10)
90.00
(9)
100.00
(3)
79.64
(133)
Accept
Transfer
18.52
(5)
4.00
(1)
5.88
(1)
6.67
(1)
9.09
(1)
0.00
(0)
25.00
(2)
20.00
(1)
42.86
(3)
37.50
(3)
0.00
(0)
8.33
(1)
20.00
(2)
0.00
(0)
12.57
(21)
Provide
Transfer
18.52
(5)
16.00
(4)
58.82
(10)
13.33
(2)
9.09
(1)
23.08
(3)
12.50
(1)
40.00
(2)
0.00
(0)
0.00
(0)
0.00
(0)
16.67
(2)
0.00
(0)
0.00
(0)
17.96
(30)
Stabilization 51.85
(14)
60.00
(15)
64.71
(11)
26.67
(4)
27.27
(3)
69.23
(9)
62.50
(5)
60.00
(3)
57.14
(4)
62.50
(5)
83.33
(5)
41.67
(5)
50.00
(5)
100.00
(3)
54.49
(91)
Violation Not
Clear
7.41
(2)
12.00
(3)
0.00
(0)
0.00
(0)
0.00
(0)
0.00
(0)
12.50
(1)
20.00
(1)
0.00
(0)
0.00
(0)
0.00
(0)
0.00
(0)
0.00
(0)
0.00
(0)
4.19
(7)
Teaching
Hospital
51.85
(14)
44.00
(11)
35.29
(6)
20.00
(3)
54.55
(6)
53.85
(7)
62.50
(5)
60.00
(3)
42.86
(3)
75.00
(6)
33.33
(2)
41.67
(5)
60.00
(6)
0.00
(0)
46.11
(77)
Continued on next page
372
AIMS Public Health Volume 5, Issue 4, 366-377.
2002
(27)
2003
(25)
2004
(17)
2005
(15)
2006
(11)
2007
(13)
2008
(8)
2009
(5)
2010
(7)
2011
(8)
2012
(6)
2013
(12)
2014
(10)
2015
(3)
Total
(167)
DSH** 2.40
(4)
5.39
(9)
2.99
(5)
1.80
(3)
1.12
(2)
1.12
(2)
1.12
(2)
0.00
(0)
0.00
(0)
0.60
(1)
0.60
(1)
2.99
(5)
1.20
(2)
0.60
(1)
22.16
(37)
Average Fine 23,815
(27)
23,300
(25)
25,882 </
