Hospital Admissions: Who Gets Turned Away And Why?

While most people believe that hospital emergency rooms cannot refuse to treat them, this is not always the case. In the 1980s, hospitals would turn away patients who couldn't pay, a practice known as patient dumping, which led to serious injuries and deaths. In response, the US government enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires Medicare-participating hospitals to provide an appropriate medical screening to determine if a patient is experiencing a medical emergency or is in active labor. Despite EMTALA, hospitals continue to turn away patients, with some hospitals paying fines for violating the statute.

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Hospitals turning away patients due to their inability to pay

In the past, hospitals would turn away patients from emergency rooms if they could not demonstrate their ability to pay. This practice, known as "patient dumping", has caused serious injury and death among patients in emergency medical conditions and active labour. The Emergency Medical Treatment and Active Labor Act (EMTALA) bans hospitals that accept Medicare patients from dumping patients. When a patient shows up at a hospital emergency room and requests care, the hospital is obligated by federal law to provide an "appropriate medical screening". An appropriate medical screening is one that includes what would be provided to a person with insurance or who could pay out of pocket. The purpose of a medical screening is to determine if the patient is experiencing an actual emergency medical condition or is in active labour.

Despite EMTALA, hospitals have continued turning patients away. This is due to the ambiguity of the statutory provisions, poor enforcement mechanisms, and divergent judicial interpretations of the statutory provisions. A 2001 Office of the Inspector General (OIG) study revealed that emergency-care personnel and hospital staff are often unaware of EMTALA provisions and policy changes, and even when they are aware, there is uncertainty about the proper interpretation and application of the provisions. Furthermore, most emergency personnel do not receive EMTALA guidelines.

In one case, a pregnant woman presented to a Victoria, Texas hospital ER near full term. She had delivered other children and felt she was in labour. The nursing staff quickly assessed the mother and found that she had a dangerously high blood pressure of 210/130 and hadn't received prenatal care because she didn't have health insurance. They called the on-call obstetrician (OB/GYN), who told them to transfer the patient to a hospital over 150 miles away. The labour and delivery nurses appropriately took it up the chain of command to the charge nurse and hospital administrator, advocating against an unsafe transfer of the patient. The OB reluctantly arrived at the hospital an hour after the patient came to the ER.

In another instance, a 57-year-old woman went to Calhoun Liberty Hospital in Blountstown, Florida, due to abdominal pain and breathing problems. The woman's family settled with the hospital for $200,000. The judge dismissed most of the family's claims, especially those dealing with false imprisonment and battery. According to a hospital representative, the woman's clot—a pulmonary embolism—is often immediate and fatal. It is difficult to detect and nearly impossible to treat.

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The violation of EMTALA

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law that prohibits hospitals from turning away patients in emergency medical conditions or active labour, regardless of their insurance status or ability to pay. Under EMTALA, hospitals are required to provide an "appropriate medical screening" to determine if a patient is experiencing an actual emergency medical condition or is in active labour. If an emergency medical condition exists, hospitals must provide stabilising treatment or an appropriate transfer to another hospital that can provide the necessary treatment.

Despite EMTALA's protections, hospitals have continued to turn away patients, a practice known as "patient dumping". This occurs when hospitals transfer or discharge patients without stabilising their emergency medical condition, often due to the patient's inability to pay. For example, a hospital in Texas attempted to transfer a pregnant woman with dangerously high blood pressure to another hospital over 150 miles away because she did not have health insurance. In another case, a Florida hospital failed to perform a medical screening on a suicidal man, who then lacerated his arm after being turned away.

To establish a violation of EMTALA, a plaintiff must demonstrate that the hospital is a Medicare-participating hospital covered by EMTALA, that the patient sought treatment, and that the hospital either failed to provide an appropriate medical screening or turned away the patient without stabilising their emergency medical condition. Individuals who believe their rights under EMTALA have been violated can file a complaint with the Centers for Medicare and Medicaid Services (CMS), which may result in civil monetary penalties for the hospital or physician involved.

The enforcement of EMTALA has been inconsistent, with some hospitals more likely to be investigated due to their proximity to CMS regional offices. Judicial interpretations of EMTALA requirements have also been conflicting, contributing to the continued violation of patient rights.

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Patient dumping

In the 1980s, hospitals would turn away people from their emergency rooms if they couldn't demonstrate an ability to pay. This practice caused serious injury and death among patients in emergency medical conditions and active labor. The Emergency Medical Treatment and Active Labor Act (EMTALA) bans hospitals that accept Medicare patients from dumping patients. When a patient shows up at a hospital emergency room (ER) and requests care, the hospital is obligated by federal law to provide an "appropriate medical screening". An appropriate medical screening is one that includes what would be provided to a person with insurance or who could pay out of pocket. After a medical screening, patients in an emergency medical condition or active labor must be medically stabilized before being discharged or transferred.

Despite EMTALA, hospitals have continued turning patients away. Forty-three of the 50 states have adopted statutes similar to the federal requirements, but the EMTALA enforcement process fails to notify hospitals that are at risk of violating the proper standard of care. In addition, regional CMS offices often do not inform state survey agencies, hospitals, and peer review organizations about their decisions, leading to inconsistent and incomplete statistics on violations.

Other factors associated with patient dumping are being part of a minority group and being uninsured. Historically, hospitals have been reported to compete against each other to maintain low mortality rates at the expense of low-income patients. Competition within hospitals to see more patients faster also increases the rate of inappropriate patient discharges. Researchers have reported that the language in COBRA was not precise enough to significantly disincentivize healthcare providers from discontinuing patient dumping practices. For example, in the 1980s, Texas state law had a loophole that allowed hospitals to transfer patients to nursing homes. In the 21st century, undocumented immigrants were reportedly subject to patient dumping by being deported or repatriated.

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Hospitals failing to provide appropriate medical screening

Hospitals are mandated by federal law to provide appropriate medical screening to patients who request treatment. This is enforced by the Emergency Medical Treatment and Active Labor Act (EMTALA), which was enacted to prevent hospitals from turning away patients due to their inability to pay. Under EMTALA, hospitals are required to screen and treat patients' emergency medical conditions in a non-discriminatory manner, regardless of their insurance status, ability to pay, race, or national origin.

Despite these legal requirements, hospitals have continued to turn away patients, a practice known as "patient dumping." This has resulted in serious injuries and even deaths among patients in emergency medical situations. In one instance, a Florida hospital failed to perform a medical screening on a suicidal man, who subsequently harmed himself. In another case, a 57-year-old woman in Florida sought medical attention due to abdominal pain and breathing problems but was sent home without receiving adequate screening.

Hospitals have three main obligations under EMTALA: firstly, anyone who requests treatment must receive a medical screening examination to determine if an emergency medical condition exists. Secondly, examination and treatment cannot be delayed to inquire about payment or insurance coverage. Finally, if an emergency medical condition is identified, treatment must be provided until the condition is resolved or stabilized.

Violations of EMTALA can result in civil monetary penalties for hospitals and physicians, with fines ranging from $59,973 to $119,942 per violation. Hospitals that fail to comply may also face termination of their provider agreements, and physicians may be excluded from participating in Medicare and state healthcare programs. Despite these consequences, the enforcement of EMTALA has been inconsistent, with some hospitals being more prone to violations due to their proximity to Centers for Medicare & Medicaid Services (CMS) regional offices.

Judicial decisions and conflicting interpretations of EMTALA

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by the US Congress in 1986 to ensure public access to emergency services regardless of ability to pay. EMTALA is also referred to as a federal "anti-dumping law", which prevents hospitals from denying or limiting treatment to patients based on their insurance status or ability to pay and transferring them to other facilities.

EMTALA has three main obligations: firstly, any individual who comes to a hospital and requests it must receive a medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists. Secondly, if an EMC is found, the hospital must provide, within its staff and facilities, further medical examination and treatment to stabilise the medical condition or transfer the individual to another medical facility. Thirdly, an "appropriate" transfer also necessitates the transportation of pertinent medical records and diagnostic findings, and the patient must be transported with qualified personnel and transportation equipment.

Since EMTALA's passage, EMTALA investigators and reviewers, as well as trial courts dealing with medical malpractice litigation, have vastly broadened the interpretation of the terms "emergency medical condition" and "to stabilize" beyond the original legislative intent and legal definitions cited in the statute. The term "appropriate MSE" has also been interpreted differently by various courts, with no specific definition provided by the Health Care Financing Administration (HCFA) or the courts.

In the context of abortion, new state laws that restrict access to reproductive health care or services could directly conflict with existing federal EMTALA obligations to provide care, putting emergency physicians in a difficult position where they must choose between their patient's health and their own exposure to liability. Following the Dobbs decision, HHS issued guidance to remind hospitals of their obligation to comply with EMTALA, including when abortion is the stabilising treatment necessary to stabilise an individual's EMC. However, a federal court ruled that HHS cannot enforce its interpretation of EMTALA in Texas, concluding that it exceeds HHS's statutory authority and that EMTALA imposes "equal" obligations with respect to both the pregnant person and their unborn child, creating a potential conflict in physician duties.

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