EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.
For those of us who practice emergency medicine, and by now any medicine in a hospital that accepts Medicare payments, no one can be turned away for financial reasons. On the surface, this seems fair. Certainly, the potential exists for gross harm and injustice if we refuse to care for the most needy in our populations because we aren’t getting paid. ‘Your child is having non-stop seizures, eh? Well, pony up $400 we’ll see what we can do!’ It makes sense to have a provision of protection.
However, because this law basically forbids hospitals and physicians from saying ‘no,’ (without a complex, time consuming, legally perilous screening exam that is rarely worth the effort), we see all those who come through the door. And because the ‘cat is out of the bag’ and has been for a while, many of our patients know this. So, we have these conversations.
Doctor: ‘I see you have a toothache. Have you seen your dentist?’
Patient: ‘No, I owe him money.’
or
Doctor: ‘You know, you’ve been here every week for the last six months for chest pain, and you’ve had every test we can do. It isn’t anything dangerous, yet you keep asking for pain medication, you refuse to follow up with anyone, and now owe our group $7000.’
Patient: ‘Right, interesting. So, today it goes around my back, to my ear, down my arm and into my testicle. What do you think it is?’
It isn’t that we don’t take people seriously, because we do. It isn’t that we don’t want to help, because we do. But medicine being our business, money is often part of the transaction after the smoke has cleared.
Equally problematic, surgeons, neurologists, cardiologists, otolaryngologists and just about every other ‘ist’ is burdened with the same issue. The people they see in the ER, admit to the floor, or take to surgery or the cardiac cath lab will frequently be unable to pay anything, but then still be able to sue for millions of dollars. It’s hard for specialists to run practices when large numbers of patients pay nothing for their care. I understand their issues here. I don’t blame them a bit for being angry.
And of course, hospitals are providing care that isn’t reimbursed to patients who can’t, or intend never to pay them. Nurses and other staff are cut. Rooms aren’t available, needed additions aren’t built, new technologies are hard to afford, other specialists can’t be recruited, and before you can blink a hospital is closing or reducing it’s capacity. And to top it off, we can’t even get the Smucker’s peanut butter cups we all used to scarf from the patient supply cabinet while seeing sick people! Woe is me!
Across America, small and medium sized emergency departments and hospitals are closing. Trauma centers and teaching hospitals are struggling and overwhelmed. And specialists are simply leaving hospital care in order to avoid being on call, and the attendant EMTALA responsibilities that call entails. They’re working in surgery/outpatient centers. They’re leaving the setting where they are compelled to give care away, and where they are constantly overwhelmed by more and more demand, less and less payment.
Our own group sees increased volume every time we increase staffing. The numbers, the lack of control, the degree of genuine illness, and the degree of ridiculous visits for life crises, narcotic abuse, work excuses or just ‘because I was here with my friend anyway,’ keep rising. Can we say no? Not much, not often.
You see, the federal government thought EMTALA seemed like a nice, friendly, warm-hearted way to help America’s indigent populations. It also thought it seemed like a cheap way to do it, since EMTALA didn’t come with any money for providers or hospitals to do this epic work of securing the ‘health-care safety net.’ Like so many government programs it consists of untold numbers of legislators and government functionaries patting themselves on the back for helping the poor by having someone else pay for it and do the work; that is, America’s hospitals and physicians.
But here’s the final irony. EMTALA has created the very conditions it sought to avoid. Now, with specialists unavailable, hospitals full, transfers always difficult and no lack of genuinely sick and dying patients, there’s often 1) no one to care for them and 2) no place to put or send them. EMTALA, the federal mandate to save the poor from sickness has begun to crumble at its foundations, and leave untold numbers of patients, poor and paying, without care.
This isn’t meant to be a tirade about payment, though non-medical readers may see it that way. What I’m getting at is that our system, our government mandated system, is a failure.
You might make the argument that nationalized health-care can fix this with money, but as we see in so many problems, money doesn’t do much. Money in the school system still leaves us with staggering drop-out rates and high-school illiteracy. Money, in the hands of an irresistible, un-yielding, entitlement crazy, grandiosity-leaning government system will probably result in an even greater disaster than EMTALA.
My suggestion? Get the government out of it all. If you do, the poor will likely get better care, since we’ll be able to screen out and turn away those who abuse their privilege. And doctors, that pesky, generally unimportant part of the medical equation, will actually return to hospitals and be available; out of a sense of duty, professionalism, entrepreneurial spirit and genuine compassion without federal compulsion.
It’s unlikely to happen, but a doctor can dream. ‘And then I saw a scarecrow and some flying monkeys and a witch, and a hospital where I was in charge and could always do what I thought was right, oh Auntie Em, it was wonderful!’
[…] Posted by GruntDoc on May 8th, 2008 The wreck of the good ship, EMTALA at edwinleap.com EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the… Read more »
[…] The wreck of the good ship, EMTALA Posted on May 8, 2008 by coptermedic From Edwin Leap, MD: […]
Steve
15 years ago
Continue to elect the same buggers to Congress…that way none of your dreams will be realized. Take responsibility by electing people that won’t “give” away our country.
Steve
Patrick
15 years ago
EMTALA and JCAHO are the two biggest obstacles to effective, efficient and compassionate care for all. All in the name of fairness and excellence.
All true. Recently the dept of homeland security counted ER beds available in big cities on a certain date, at a certain time and found few available. The idea was how many would be available in a terrorist attack. Who do you think were probably taking up half of these beds?
No one listens to doctors anymore. Neither will Congress.
I just read your article in Medical Economics. Congratulations. It was nice.
Tammy, MD
15 years ago
Once again, Dr. Leap, you are a voice of reason in what seems like an ocean of nonsense! I practice in small town ED (census 46K visits/year) and have watched my list of specialists on call dwindle (No ENT, GI, Urology, Neurology, or Opthomology.. don’t even think about neurosurg, plastics, trauma surgery) I’ll be honest…it has gotten downright frightening! This winter was a nightmare since most of the “big city” hospital beds were filled to the brim. My ortho guys cringe to take any call, because they get pulled out of an office of paying patients to see patients who… Read more »
The “silent protest” by doctors and specialists walking away from hospital practice is certainly appropriate and moral. And I agree fully that we should “Get the government out of it all.” But it doesn’t have to be just a dream. The real power in the health care arena is the doctor, and he should use it. Fleeing the hospitals for surgery/outpatient centers or some other means of practice is only a short-term fix. The politicians will eventually go after them wherever they go. The best, and likely the only, way to turn the tide toward a full-fledged government-run health care… Read more »
ninguem
15 years ago
Is this a new position for you Dr. Leap?
I’ve long held the position that EMTALA makes things worse, but I seem to be under the impression that EM physicians did not share the feeling. I don’t think we’ll have any action on this law until organized Emergency Medicine takes the position that the law should be repealed.
dear dr leap.
long, long time fan. now that i have a semi-successful blog i find myself linking you quite frequently and you are linked for this one my friend. at the time you were writing this piece i was writing two others which you can peruse if you choose. when are we going to link arms as physicians and hold our breath until we change this idiocy? the sermo letter is namby pamby and i’ll have a suggested letter up soon. please keep it up, my wife and i love your stuff.
me
Long, long ago, I took a friend to a local community hospital/medicaid clinic to seek treatment for his headache. It turned out he had a mild sinus infection, easily treated. But we had to wait approximately eight hours in a small, cramped waiting room before he got to speak with a doctor. Nationalized health care would be this, but worse. Instead of waiting eight hours, the hours would turn into days and weeks, maybe even months. This has been the experience of many of my Canadian friends who live under a nationalized health care system. “You need cataract surgery and… Read more »
Although it may sound a bit corny, I in reality like looking after my hearing and whilst I do agree with the preceding poster and I really hope I do not get shot down for saying this, but I think it is essential to take all things in moderation.
19.) Oh my goodness! an amazing article dude. Thank you However I am experiencing issue with ur rss . Don’t know why Unable to subscribe to it. Is there anyone getting identical rss problem? Anyone who knows kindly respond. Thnkx
I have learned new things from a blog post. Also a thing to I have observed is that in many instances, FSBO sellers can reject people. Remember, they might prefer to not ever use your services. But if a person maintain a gentle, professional relationship, offering guide and staying in contact for about four to five weeks, you will usually have the ability to win a meeting. From there, a house listing follows. Many thanks
Hello there, just became alert to your blog through Google, and found that it is truly informative. I am gonna watch out for brussels. I’ll be grateful if you continue this in future. A lot of people will be benefited from your writing. Cheers! It’s perfect time to make some plans for the future and it’s time to be happy. I have read this post and if I could I want to suggest you some interesting things or tips. Maybe you can write next articles referring to this article. I want to read more things about it! Great post. I… Read more »
I had been wanting to know if you ever thought of replacing the layout of your web site? Its very well written; I enjoy what you have got to say. But maybe you can create a a bit more in the way of content so people can connect with it better. You have got an awful lot of text for only having one or two graphics. Maybe you can space it out better?
Anthony Barthelemy
12 years ago
Hey, I found webblog is awfully attention-grabbing. I liked your webblog a lot. Thanks again for sharing this online. I certainly loved every part of it.
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I’m commenting to let you know of the outstanding encounter my cousin’s child went through reading the blog. She figured out a lot of pieces, most notably what it is like to have a very effective helping nature to make a number of people without difficulty fully understand several impossible topics. You actually exceeded readers’ desires. I appreciate you for producing these informative, trustworthy, revealing as well as unique guidance on this topic to Lizeth.
Thanks for all your efforts on this website. Gloria loves going through investigations and it is obvious why. Most people notice all of the dynamic method you convey very useful ideas on the blog and therefore welcome response from website visitors about this idea so my child is undoubtedly starting to learn a lot. Enjoy the remaining portion of the new year. You are performing a really good job.
Thank you for the auspicious writeup. It actually was a entertainment account it.
Glance complex to more added agreeable from you! By the
way, how could we communicate?
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[…] Posted by GruntDoc on May 8th, 2008 The wreck of the good ship, EMTALA at edwinleap.com EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the… Read more »
[…] The wreck of the good ship, EMTALA Posted on May 8, 2008 by coptermedic From Edwin Leap, MD: […]
Continue to elect the same buggers to Congress…that way none of your dreams will be realized. Take responsibility by electing people that won’t “give” away our country.
Steve
EMTALA and JCAHO are the two biggest obstacles to effective, efficient and compassionate care for all. All in the name of fairness and excellence.
Pathetic.
All true. Recently the dept of homeland security counted ER beds available in big cities on a certain date, at a certain time and found few available. The idea was how many would be available in a terrorist attack. Who do you think were probably taking up half of these beds?
No one listens to doctors anymore. Neither will Congress.
I just read your article in Medical Economics. Congratulations. It was nice.
Once again, Dr. Leap, you are a voice of reason in what seems like an ocean of nonsense! I practice in small town ED (census 46K visits/year) and have watched my list of specialists on call dwindle (No ENT, GI, Urology, Neurology, or Opthomology.. don’t even think about neurosurg, plastics, trauma surgery) I’ll be honest…it has gotten downright frightening! This winter was a nightmare since most of the “big city” hospital beds were filled to the brim. My ortho guys cringe to take any call, because they get pulled out of an office of paying patients to see patients who… Read more »
The “silent protest” by doctors and specialists walking away from hospital practice is certainly appropriate and moral. And I agree fully that we should “Get the government out of it all.” But it doesn’t have to be just a dream. The real power in the health care arena is the doctor, and he should use it. Fleeing the hospitals for surgery/outpatient centers or some other means of practice is only a short-term fix. The politicians will eventually go after them wherever they go. The best, and likely the only, way to turn the tide toward a full-fledged government-run health care… Read more »
Is this a new position for you Dr. Leap?
I’ve long held the position that EMTALA makes things worse, but I seem to be under the impression that EM physicians did not share the feeling. I don’t think we’ll have any action on this law until organized Emergency Medicine takes the position that the law should be repealed.
dear dr leap.
long, long time fan. now that i have a semi-successful blog i find myself linking you quite frequently and you are linked for this one my friend. at the time you were writing this piece i was writing two others which you can peruse if you choose. when are we going to link arms as physicians and hold our breath until we change this idiocy? the sermo letter is namby pamby and i’ll have a suggested letter up soon. please keep it up, my wife and i love your stuff.
me
https://docsontheweb.blogspot.com/2008/05/consults-circa-emtala.html
https://docsontheweb.blogspot.com/2008/05/all-your-medical-news-right-here.html
Long, long ago, I took a friend to a local community hospital/medicaid clinic to seek treatment for his headache. It turned out he had a mild sinus infection, easily treated. But we had to wait approximately eight hours in a small, cramped waiting room before he got to speak with a doctor. Nationalized health care would be this, but worse. Instead of waiting eight hours, the hours would turn into days and weeks, maybe even months. This has been the experience of many of my Canadian friends who live under a nationalized health care system. “You need cataract surgery and… Read more »
Although it may sound a bit corny, I in reality like looking after my hearing and whilst I do agree with the preceding poster and I really hope I do not get shot down for saying this, but I think it is essential to take all things in moderation.
19.) Oh my goodness! an amazing article dude. Thank you However I am experiencing issue with ur rss . Don’t know why Unable to subscribe to it. Is there anyone getting identical rss problem? Anyone who knows kindly respond. Thnkx
I have learned new things from a blog post. Also a thing to I have observed is that in many instances, FSBO sellers can reject people. Remember, they might prefer to not ever use your services. But if a person maintain a gentle, professional relationship, offering guide and staying in contact for about four to five weeks, you will usually have the ability to win a meeting. From there, a house listing follows. Many thanks
Youre one of the good guys here, and we know that. Its not the numbers, its the abuse.
Hello there, just became alert to your blog through Google, and found that it is truly informative. I am gonna watch out for brussels. I’ll be grateful if you continue this in future. A lot of people will be benefited from your writing. Cheers! It’s perfect time to make some plans for the future and it’s time to be happy. I have read this post and if I could I want to suggest you some interesting things or tips. Maybe you can write next articles referring to this article. I want to read more things about it! Great post. I… Read more »
As many have no doubt noted already, the supreme irony of this contest is if a guy named Kennedy effectively throws the Kennedy seat to the GOP.
I had been wanting to know if you ever thought of replacing the layout of your web site? Its very well written; I enjoy what you have got to say. But maybe you can create a a bit more in the way of content so people can connect with it better. You have got an awful lot of text for only having one or two graphics. Maybe you can space it out better?
Hey, I found webblog is awfully attention-grabbing. I liked your webblog a lot. Thanks again for sharing this online. I certainly loved every part of it.
Yeah, those Garmin doohickeys are kinda magical. I might have to get one now. Oh dear.
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Thanks for all your efforts on this website. Gloria loves going through investigations and it is obvious why. Most people notice all of the dynamic method you convey very useful ideas on the blog and therefore welcome response from website visitors about this idea so my child is undoubtedly starting to learn a lot. Enjoy the remaining portion of the new year. You are performing a really good job.
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Thank you for the auspicious writeup. It actually was a entertainment account it.
Glance complex to more added agreeable from you! By the
way, how could we communicate?
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