EMTALA most impactful change in past two decades
Boarding, reduced safety unintended consequences
A lot can happen in 20 years, and certainly a lot has happened in the practice of emergency medicine — both good and bad. But experts seem to agree that no single event has had more impact on the field than the passage of the Emergency Medical Treatment and Labor Act (EMTALA).
"EMTALA is an unfunded mandate, and we have borne the brunt of it," says Nicholas Jouriles, MD, FACEP, president of the American College of Emergency Physicians (ACEP). "ED physicians provide more than $150,000 each of free care per year — magnitudes more than any other specialty."
That's because EDs often have no choice but to treat patients under EMTALA, while specialists often do have a choice, he says. "We've seen patients suffer because of that," Jouriles says. "It's one of the reasons we've seen more boarding, along with more likely complications, longer lengths of stay, and more patient deaths."
Robert Bitterman, MD, FACEP, president of Bitterman Health Law Consulting Group in Harbor Springs, MI, agrees. "EMTALA gave a lot of people access to care, but there are no primary care physicians anymore," he notes. "Specialists are cutting back, specifically not to take care of ED patients."
In many cases, he notes, those specialists are changing their privileges. Some neurosurgeons, for example, are reclassifying themselves as spine surgeons "so as to not have to be associated with all the other neurosurgery stuff that has much higher liability," he says. At some point, Bitterman predicts, the situation will hit home in a very public way. "Some senator's daughter is going to be transferred 90 miles with head bleed, and she is going to die," he says.
James J. Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group in Canton, OH, cites another governmental action as a major development of the past 20 years. "There was a 1994 GAO [Government Accounting Office] report that said at least half of the patients in EDs could receive care elsewhere and, to this day, government leaders talk about the ED as the most expensive site of care where people do not need to be," he says. "Probably no single document has been more damaging to our industry than that."
That's because politicians, community health departments, and hospital boards decided that if most of those patients did not belong in the ED, there was no reason to expand EDs because that would just "invite" more of these patients to show up, he says. "That's resulted in a pattern of chronic underfunding," Augustine says.
A lot can happen in 20 years, and certainly a lot has happened in the practice of emergency medicine both good and bad. But experts seem to agree that no single event has had more impact on the field than the passage of the Emergency Medical Treatment and Labor Act (EMTALA).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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