Understanding the Current State of EMTALA: Separating EMTALA From State Law Medical Malpractice
The Emergency Medical Treatment and Active Labor Act (“EMTALA”), enacted in 1986, remains a foundational federal law governing the responsibilities of hospitals to provide emergency medical care. Although the Act has greatly developed since its enactment, the law continues to carry critical legal and clinical implications for hospitals that MPL defense attorneys should be aware of.
Here is a breakdown of what EMTALA is, what it isn’t, and what is required for an individual to prevail on a private right of action for a violation under this law. Importantly, this article will focus specifically on the emergency medical care portion of EMTALA and will not address the requirements under EMTALA when active labor is present.
What is EMTALA and Why Was it Enacted?
The enactment of EMTALA by Congress in 1986 came after physicians at Chicago’s Cook County Hospital exposed the extent of patient dumping to that facility in two pieces of literature. [1] [2] The authors defined patient dumping as “the denial or limitation in the provision of medical services to a patient for economic reasons and the referral of that patient elsewhere.” (1). These articles indicated in 87% of transfers to Cook County Hospital, the reason given by the transporting facility for the transfer was lack of insurance. Furthermore, only 6% of these patients had given written informed consent for the transfer and only 24% were considered to have been transferred in an unstable condition. Thus, in an effort to prevent this practice, EMTALA, also commonly referred to as the Patient Anti-Dumping Act, was born.
Although originally designed with those in mind who lacked insurance or were low-income, EMTALA ensures that all individuals have access to emergency care, regardless of their insurance status or ability to pay. The duties imposed by EMTALA on hospitals who participate in Medicare and have an emergency department have remained the same since 1986.The statute imposes three primary obligations:
1. Medical Screening Examination (MSE): Hospitals must provide an appropriate MSE to anyone who comes to the emergency department seeking medical care to determine whether an emergency medical condition exists (EMC).
2. Stabilization: If an EMC exists, the hospital must provide treatment to stabilize the condition before discharge or transfer.
3. Appropriate Transfer: If a hospital lacks the appropriate capacity to stabilize the EMC, it must arrange for an appropriate transfer to a facility that can provide the necessary care.
In practice, many of the EMTALA cases that have reached courts have been dismissed as being state law medical malpractice claims not properly brought under EMTALA. The confusion between ETMALA and medical malpractice likely results from the extremely vague statutory screening standard, requiring hospital emergency departments to render “an appropriate medical screening examination,” without defining what such a screening entailed. The only hint provided by the statute is that such medical screening must be calculated to determine whether an EMC exists.
EMTALA Does Not Incorporate an Objective Standard of Care.
It’s been observed that since EMTALA only requires hospital to screen within the capabilities of that specific hospital’s emergency department, EMTALA could not be intended to incorporate the objective malpractice standard of care. However, if the statute does not impose an objective standard of care, then what determines whether a medical screening examination was appropriate? Taking into consideration that the statute acknowledges the differing levels of resources available amongst hospitals, there was only one option for how to establish such a standard – referencing the specific hospital’s standard screening procedures.
Applying a different standard for each individual hospital seems like an inconceivable idea and one that would make any attorney’s head hurt. However, this idea was concocted, as well as further supported and utilized, by the courts themselves. Therefore, a hospital fulfills the “appropriate medical screening examination” requirement under EMTALA when it confirms in its treatment of a particular patient to its own standard screening procedure. In order words, for a patient to show that the screening examination or treatment received at a hospital violated EMTALA, the patient must show that the hospital failed to comply with its own standards.
EMTALA Does Not Require a Correct Diagnosis or Non-Negligent Treatment.
As mentioned, under EMTALA, hospitals are required to give anyone who presents to the emergency department seeking medical care an appropriate MSE to determine if an EMC exists. But what counts as an “appropriate” examination doesn’t mean the diagnosis resulting from that MSE must be correct – it just means the screening provided is a uniform one. In other words, as long as a hospital is following its standard screening procedures, it is complying with EMTALA even if the results of the screening are incorrect.
The exact same concept applies in regard to the treatment following a diagnosis. EMTALA is implicated only when individuals who are perceived to have the same medical condition receive disparate treatment; it is not implicated whenever individuals who turn out in fact to have had the same condition receive disparate treatment. EMTALA would otherwise become indistinguishable from state malpractice law. Thus, as a result, when an exercise in medical judgment produces a given diagnosis, the decision to prescribe a treatment responding to the diagnosis cannot form the basis of an EMTALA claim of inappropriate screening. In fact, not only does treatment based on diagnostic medical judgment not violate the Act, it is precisely what EMTALA hoped to achieve—handling of patients according to an assessment of their medical needs, without regard to extraneous considerations such as their ability to pay.
EMTALA Does Not Require the Stabilization of an Unknown Emergency Medical Condition.
Under the second obligation of EMTALA, once a hospital determines that an EMC exists, it is required to stabilize the condition. But what if a hospital’s misdiagnosis fails to reveal an undetected EMC and thus fails to stabilize that condition? EMTALA does not apply- whether a patient is in fact suffering from an EMC is irrelevant. Instead, what matters under EMTALA is the hospital’s determination of the patient’s medical status since the standard for a failure to stabilize claim is a subjective one.
EMTALA only requires hospitals to stabilize a patient after they have identified an emergency medical condition exists. The Act does not hold hospitals accountable for failing to stabilize conditions of which they are not aware, or even conditions of which they should have been aware. As frequently mentioned, EMTALA is about ensuring that individuals are uniformly treated –not second-guessing a hospital’s judgment after the fact. A hospital’s duty to stabilize is determined in reference to the diagnosis, not in hindsight for what a patient turned out to have. In order for a plaintiff to prevail on a failure to stabilize claim under EMTALA, the plaintiff must show that an emergency medical condition existed, and that the hospital was aware of the seriousness of the medical condition but nevertheless failed to stabilize it.
A Final Word
Given these various nuances present in civil cases involving EMTALA—and the significant differences from the typical medical malpractice cases that courts are more familiar with—there is a critical need to educate judges and attorneys on EMTALA’s requirements to ensure consistent outcomes and uphold the Act’s intended purpose.
EMTALA does not act as a substitute for a medical malpractice claim requiring a correct diagnosis and non-negligent treatment or penalizing a hospital for failing to detect and stabilize an emergency medical condition. Instead, EMTALA requires uniform treatment amongst all individuals that present to an emergency room seeking medical care. Understanding these distinctions is crucial when defending a private civil action for damages as a result of an alleged EMTALA violation.
[1] Ansell DA, Schiff RL. Patient Dumping: Status, Implications, and Policy Recommendations. JAMA. 1987;257(11):1500–1502.doi:10.1001/jama.1987.03390110076030. (https://jamanetwork.com/journals/jama/article-abstract/365084)
[2] Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S. Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med. 1986; 314:552–557.doi: 10.1056/NEJM198602273140905. (https://www.nejm.org/doi/abs/10.1056/NEJM198602273140905)
