Emtala And Private Psychiatric Hospitals: Who's Covered?

The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 to prevent hospitals from refusing to treat patients with medical emergencies due to their inability to pay. While EMTALA applies to psychiatric patients, ensuring they have access to physicians, there is ambiguity around its application to psychiatric hospitals. EMTALA mandates that hospitals with the specialists needed to stabilize emergency medical conditions must accept patients from hospitals lacking these specialists. However, it does not ensure timely access to specialists optimally trained in psychiatric care. To be held liable for an EMTALA violation, a psychiatric facility must meet specific criteria, including being licensed as a hospital, participating in the Medicare program, and operating a dedicated emergency department (DED). The Centers for Medicare and Medicaid Services (CMS) have issued clarifications, stating that intake areas in psychiatric hospitals may qualify as DEDs, requiring EMTALA compliance. Nonetheless, the application of EMTALA to psychiatric hospitals remains complex, and further clarification is needed to ensure equitable access to psychiatric care.

EMTALA and the treatment of psychiatric patients

EMTALA, or the Emergency Medical Treatment and Active Labor Act, was enacted in 1986 to counteract the growing problem of "patient dumping," the practice of hospitals refusing treatment to people with medical emergencies because of their inability to pay. EMTALA ensures that psychiatric patients have access to physicians, but it does not ensure timely access to specialists optimally trained to provide definitive care for their illnesses. While emergency physicians can prevent self-harm and manage acute psychosis, they are not trained in behavioural therapy and medication management, which are crucial for patients' recovery from underlying psychiatric illnesses.

There is ambiguity around the application of EMTALA requirements to psychiatric hospitals. However, it is clear that EMTALA applies to hospitals that meet the following criteria: licensed as a hospital under state law, participating in the Medicare program, and operating a dedicated emergency department (DED). The Centers for Medicare and Medicaid Services (CMS) define a DED as a department licensed as an emergency department, one that holds itself out as a provider of emergency services, or a department that sees at least one-third of its patients on an unscheduled basis for potential emergency medical conditions.

Psychiatric disturbances can be considered emergency medical conditions. If a patient presents with such a condition, the hospital is required to screen and stabilize them within its capabilities. It is a violation of EMTALA for a hospital to transfer a patient when it has the capability to stabilize or admit them. Similarly, it is a violation to refuse to accept a transfer of a patient with an emergency medical condition if the hospital has the capability to provide care.

The application of EMTALA to psychiatric hospitals has been the subject of recent clarifications by CMS. In 2019, CMS issued a letter to State Survey Agency Directors with Frequently Asked Questions (FAQ) on the topic. CMS noted that intake or assessment areas in psychiatric hospitals might meet the threshold of a "dedicated emergency department," requiring compliance with EMTALA's medical screening and stabilizing treatment requirements. However, there is no expectation for psychiatric hospitals with basic clinical services to provide the same comprehensive assessments or treatments as acute care hospitals.

EMTALA's application to private psychiatric hospitals

EMTALA, or the Emergency Medical Treatment and Labor Act, was enacted in 1986 to counteract the growing problem of "patient dumping", the practice of hospitals refusing to treat people with medical emergencies because of their inability to pay. While EMTALA ensured that psychiatric patients had access to physicians, it did not ensure timely access to specialists optimally trained to provide definitive care for their illnesses.

There is a widespread misconception among freestanding psychiatric facilities that EMTALA does not apply to them. This may or may not be true depending on the facility's licensure and configuration. For a facility to be held liable for an EMTALA violation, it must meet three criteria: it must be licensed as a hospital under state law, participate in the Medicare program, and operate a dedicated emergency department (DED).

The Centers for Medicare and Medicaid Services (CMS) has clarified that intake or assessment areas in psychiatric hospitals may meet the threshold of a DED, requiring compliance with EMTALA's medical screening and stabilizing treatment requirements. This means that psychiatric hospitals without a DED must still perform medical screening examinations and provide stabilizing treatment within their capabilities.

EMTALA regulations also apply to hospitals without a DED, such as the requirement that Medicare-participating hospitals with specialized capabilities may not refuse to accept a patient transfer from a referring hospital if the patient requires those specialized capabilities. Additionally, it is a violation of EMTALA for a hospital to transfer a patient when it has the capability to stabilize or admit them.

While EMTALA is enforceable by potentially large financial penalties, it is sparingly applied to mental health transfers. This has led to a situation where patients with psychiatric needs are moved out of emergency departments to free up beds for financially profitable medical patients, creating a shortage of beds for uninsured and underinsured patients.

The IMD exclusion act and its impact on psychiatric care

The IMD exclusion act has had a profound impact on psychiatric care in the United States. The act, which is part of the Social Security Act, prohibits Medicaid funds from being used to cover an individual's care at an Institution of Mental Disease (IMD). IMDs are defined as psychiatric hospitals or residential treatment facilities with more than 16 beds that primarily diagnose or treat people with behavioural health disorders, including substance use disorder.

This exclusion has limited access to psychiatric care for many, particularly those who rely on Medicaid for their healthcare coverage. As a result, individuals with mental illness may end up in jail or on the streets, leading to worse outcomes for the person, greater pain for their families, and higher costs for state and federal governments. The act has also disincentivized the expansion of mental healthcare facilities, with the number of beds often reduced to protect the monetary interests of large health systems.

The IMD exclusion was created as part of the deinstitutionalization movement, shifting funding responsibility for inpatient psychiatric services from the federal government to individual states. While the intention was to protect patients from maltreatment associated with mass institutionalization, the policy has instead disempowered localities from providing adequate behavioural healthcare. The strict criteria for IMDs have resulted in unequal coverage of mental healthcare, with many individuals being denied treatment due to their behavioural health status.

Efforts have been made to improve access to mental healthcare and mitigate the negative impact of the IMD exclusion. For example, state Medicaid waiver innovations have proposed temporary solutions, such as allowing states to cover short-term stays in psychiatric hospitals. However, these waivers are restricted by total treatment days, primary diagnosis, and implementation processes. In 2019, a bill was introduced in California to expand the Emergency Medical Treatment and Active Labor Act (EMTALA) to include Acute Psychiatric Hospitals (APHs), which would subject psychiatric care to the same rules and regulations as other medical specialities.

EMTALA violations and their consequences

EMTALA, or the Emergency Medical Treatment and Labor Act, ensures that psychiatric patients have access to physicians. However, it does not ensure timely access to specialists optimally trained to provide the definitive care needed to treat their illnesses. While EMTALA is enforceable by potentially large financial penalties, it is sparingly applied to mental health transfers.

There are three criteria that must be met before a facility can be held liable for an EMTALA violation:

• It must be licensed as a hospital under state law.
• It must participate in the Medicare program.
• It must operate a dedicated emergency department (DED).

If a patient comes to a hospital’s DED seeking treatment for what may be an emergency medical condition, the hospital is required to screen the individual to determine whether they have an emergency medical condition. Psychiatric disturbances can be emergency medical conditions. If an emergency medical condition is identified, the patient must be stabilised within the hospital's "capabilities", and/or arrangements must be made for the transfer of the patient to a hospital that can appropriately stabilise and/or treat the patient.

It is a violation of EMTALA for a hospital to transfer a patient when it has the capability to stabilise or admit the patient. It is also a violation for a hospital to refuse to accept a transfer of a patient with an emergency medical condition if it has the capability to provide care for that patient.

Failure to adhere to the three duties required by EMTALA can result in serious patient injury or death, which opens the door for civil litigation. For example, a South Carolina hospital entered into a $1,295,000 settlement agreement with OIG in 2017 regarding allegations that the hospital violated EMTALA in 36 incidents. In these incidents, individuals presented to the hospital’s ED with unstable psychiatric EMCs. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit, the patients were involuntarily committed and kept in the ED for between 6 and 38 days each.

The role of emergency departments in psychiatric hospitals

The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 to prevent "patient dumping", the practice of hospitals refusing treatment to people with medical emergencies due to their inability to pay. EMTALA ensured that psychiatric patients had access to physicians, but it did not ensure timely access to specialists optimally trained to provide definitive care for their illnesses. While emergency physicians are trained in preventing self-harm and managing acute psychosis, they are not skilled in behavioural therapy and medication management, which are crucial for patients' recovery from underlying psychiatric illnesses.

Emergency departments (EDs) in psychiatric hospitals play a crucial role as the de facto safety net for many patients with mental illnesses. However, there is ambiguity regarding the application of EMTALA requirements to psychiatric hospitals. To be held liable for an EMTALA violation, a facility must meet three criteria: it must be licensed as a hospital under state law, participate in the Medicare program, and operate a dedicated emergency department (DED).

The Centers for Medicare and Medicaid Services (CMS) define a DED as a department licensed as an emergency department, one that holds itself out as a provider of emergency services, or a department that sees at least one-third of its patients on an unscheduled basis for potential emergency medical conditions. CMS has clarified that intake or assessment areas in psychiatric hospitals may meet the threshold of a DED, requiring compliance with EMTALA's medical screening and stabilisation requirements.

EMTALA regulations place special responsibilities on Medicare-participating hospitals in emergency cases, requiring them to provide medical screening examinations and stabilising treatments. However, there is no expectation for psychiatric hospitals with basic clinical services to provide the same comprehensive assessments or treatments as acute care hospitals. Nevertheless, EMTALA violations can result in significant financial penalties, and psychiatric hospitals that exclude uninsured patients may face legal consequences.

Frequently asked questions