Consumer group finds hundreds of EMTALA violations

Public Citizen says hospitals must do a better job of caring for uninsured emergency patients; hospitals say patient dumping is rare.

By Tanya Albert, amednews staff. July 30, 2001.

The government cited 527 hospitals in the United States and Puerto Rico -- about 9% of all hospitals -- for violations of the Emergency Medical Treatment and Active Labor Act over the past several years, according to a new report by Public Citizen.

The consumer watchdog group, founded by Ralph Nader, called the violations a "disgrace."

EMTALA actions
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"It's distressing that this law has been in place for 15 years and hospitals are still [flouting] it," said Sidney M. Wolfe, MD, director of Public Citizen's Health Research Group and co-author of the report. "The government needs to do more to force the hospitals to comply."

Congress enacted EMTALA in 1986 to stop hospitals from turning away patients without insurance -- a practice commonly called patient dumping.

Public Citizen's sixth report on the issue, which covered violations in 1997, 1998, 1999 and parts of 1996 and 2000, confirmed violations at hospitals in 46 states, the District of Columbia and Puerto Rico. Delaware, Hawaii, New Mexico and Wyoming were the four states where no hospitals had confirmed violations.

The report highlights the most egregious violations, including an incident in which a surgeon repeatedly refused to come in to see a patient with a suspected abdominal condition requiring surgery. After the surgeon arrived, he made disparaging remarks about the patient's mental retardation, according to the report. The patient died.

Dr. Wolfe said the $50,000 fine associated with an EMTALA violation needs to be increased and fines need to be enforced more often to deter hospitals. Of the 500 hospitals that could have been fined during the study period, only 85 had been charged as of April, according to the report.

"The sad truth is that it's cheaper for a hospital to break the law and pay a fine than to treat an uninsured patient," Dr. Wolfe said. "Hospitals know that the risk of getting caught is low, and even if they are caught, the risk of being fined is even lower."

Taking issue with the conclusions

But some emergency physicians and the American Hospital Assn. say the Public Citizen report skews the numbers in an example of the "misuse of information."

The American Hospital Assn. points out that emergency departments have more than 100 million visits annually. "What this report does is highlight the exceptions, not the rule," said Maureen D. Mudron, Washington counsel for the AHA.

"This is not to excuse anything these hospitals or physicians did with an adverse outcome for the patient," added Arizona emergency physician Todd B. Taylor, MD, who teaches physicians about EMTALA. "But the [four-year] denominator is 400 million. Statistically, this is an extraordinarily small number of problems."

Dr. Taylor also said some of the violations may not have harmed patient care. Because EMTALA is complicated and extraordinarily hard to comply with, it's not unusual for hospitals to be cited with technical EMTALA violations even though the patient got the proper care, he said.

Hospitals and physicians say they take EMTALA seriously and don't flout it.

As EMTALA's scope continues to expand, hospitals are hosting education programs to make sure physicians and staff understand the law, Mudron and Dr. Taylor said.

"Everything we're seeing is that there is a demand to talk about the ambiguities and the views of the government," Mudron said.

EMTALA has had a positive impact on emergency departments, said Paul Stiegler, MD, a veteran of more than 20 years in EDs. He said that when he first started practicing, he saw patient dumping. Now, he said, physicians err on the side of caution, keeping a person in the ED longer than sometimes necessary just to make sure there's not a problem.

"EMTALA for the most part is working," Dr. Stieger said. "Physicians don't want to be brought up on an EMTALA violation."

ADDITIONAL INFORMATION:

EMTALA actions

Since EMTALA was enacted in 1986, the Centers for Medicare and Medicaid Services has referred 975 cases involving hospitals and physicians to the Office of Inspector General.
Of the referred cases, 261 -- or 26.7% -- resulted in fines.
In the past decade, annual fines have increased. In OIG fiscal year 1988, the government collected $130,000 in fines. In each of the fiscal years 1998, 1999 and 2000, more than $1 million was collected.
Between 1997 and April 9, 2001, 13 physicians paid civil monetary penalties to resolve alleged EMTALA violations. The average amount they paid: $19,967.
In 1995 and 1996, the average physician penalty was $11,250.

Source: Public Citizen Health Research Group