Health Care Law

EMTALA
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STATUTORY EXCEPTIONS TO COMMON LAW

I. EMTALA (Emergency Medical Treatment and Labor Act)
A. Was enacted in response to patient dumping, a practice in which patients are transferred from
one hospitals emergency room to anothers for other than therapeutic reasons
1. Lack of insurance was the reason given for 87% of the transfers
2. EMTALA: applies only to hospitals that accept payment from Medicare and operate an
emergency department; however, EMTALA applies to all patients of such a hospital and not
just to Medicare beneficiaries
3. EMTALA does not require a hospital to offer emergency room services, although some state
statutes do and federal tax law strongly encourages tax-exempt hospitals to do so
B. 2007, CMS began requiring that all hospitals participating in Medicare, including those without
dedicated emergency departments, be capable of providing initial treatment in emergency
situations as well as arrange for referral or transfer to more comprehensive facilities as a matter
of compliance with the Medicare Conditions of Participation (COPs) for hospitals
C. EMTALA: specifically empowers patients to bring civil suits for damages against participating
hospitals, but does not provide the right of action against a treating physician

II. Emergency Medical Treatment and Labor Act
A. Medical screening requirement: In the case of a hospital that has a hospital emergency
department, if any individual. Comes to the emergency department and a request is made on
the individuals behalf for examination or treatment for a medical condition, the hospital must
provide for an appropriate medical screening examination within the capability of the hospitals
emergency department, including ancillary services routinely available to the emergency
department, to determine whether or not an emergency medical condition exists
B. Necessary stabilizing treatment for emergency medical conditions and labor.
(1) In general. If any individual comes to a hospital and the hospital determines that the
individual has an emergency medical condition, the hospital must provide either
(A) Within the staff and facilities available at the hospital, for such further medical treatment
as may be required to stabilize the medical condition, or
(B) For transfer of the individual to another medical facility in accordance with subsection (c)
C. Restricting transfers until individual stabilized:
(1) Rule: if an individual at a hospital has an emergency medical condition which has not been
stabilized.., the hospital may not transfer the individual unless
(A)(i) the individual (or a legally responsible person acting on the individuals behalf) after
being informed of the hospitals obligations under this section and of the risk of transfer, in
writing requests transfer to another medical facility,
(ii) a physician. Has signed a certification that, based upon the information available at the
time of transfer, the medical benefits reasonably expected from the provision of appropriate
medical treatment at another medical facility outweigh the increased risks to the individual
and, in the case of labor, to the unborn child form effecting the transfer, or
(iii) [if no physician is available, another qualified person has signed the certificate]and
(B): the transfer is an appropriate transfer to that facility.
(2) Appropriate Transfer: an appropriate transfer to a medical facility is a transfer:
(A) in which the transfer hospital provides the medical treatment within its capacity
which minimizes the risks to the individuals health and, in the case of a woman in labor, the
health of the unborn child;
(B) in which the receiving facility
Health Care Law
EMTALA
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(i) has available space and qualified personnel for the treatment of the individual,,
and
(ii) has agreed to accept transfer of the individual and to provide appropriate
medical treatment
(C) In which the transferring hospital sends to the receiving facility all medical
recordsrelated to the emergency condition for which the individual has presented,
available at the time of transfer; [and]
(D) In which the transfer is effected through qualified personnel and transportation
D. Enforcement:
1. Civil monetary penalties.
(A) A participating hospital that negligently violates a requirement of this section is subject to
a civil money penalty of not more than $50,000 each such violation.
(B) Any physician who is responsible for the examination, treatment, or transfer of an
individual in a participating hospital and who negligently violates a requirement of this
section is subject to a civil money penalty of not more than $50,000 for each such
violation and, if the violation is gross and flagrant or is repeated, to exclusion from
participation in Medicare and Medicaid
2. Civil Enforcement:
(A) Personal Harm: any individual who suffers personal harm as a direct result of a
participating hospitals violation of a requirement of this section may, in a civil action
against the participating hospital, obtain those damages available for personal injury
under the law of the State in which the hospital is located, and such equitable relief as is
appropriate
(B) Financial loss to other medical facility. Any medical facility that suffers a financial loss
as a direct result of a participating hospitals violation of a requirement of this section
may, in a civil action against the participating hospital, obtain those damages available
for financial loss, under the law of the State in which the hospital is located, and such
equitable relief if appropriate
E. Definitions:
1. Emergency Medical Condition:
(A) A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical attention could
reasonably be expected to result in
(i) Placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman and her unborn child) in serious jeopardy,
(ii) Serious impairment to bodily functions, or
(iii) Serious dysfunction of any bodily organ or part; or
(B) With respect to a pregnant woman who is having contractions
(i) That there is inadequate time to effect a safe transfer to another hospital before
delivery, or
(ii) That transfer may pose a threat to the health or safety of the woman or the unborn
child.
2. To Stabilize: to provide such medical treatment of the condition as may be necessary to
assure, within reasonable medical probability, that no material deterioration of the condition
is likely to result from or occur during the transfer of the individual form a facility
3. Stabilized: that no material deterioration of the condition is likely, within reasonable medical
probability, to result from or occur during the transfer of the individual form a facility, or ,
with respect to an emergency medical condition described in paragraph (1)(B), that the
woman has delivered (including the placenta)
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F. No delay in examination or treatment: A participating hospital may not delay provision of an
appropriate medical screening examination required under subsection (a) or further medical
examination and treatment required under subsection (b) in order to inquire about the
individuals methods of payment or insurance status

III. Baber v. Hospital Corporation America:
1. Facts: , admin of estate of sister, instituted this suit against s Dr. Kline, Dr. Whelan, and
Raleigh General Hospital, Beckley Appalachian Regional Hospital, and the parent corporations
of both hospitals. alleged that violated EMTALA by: (1) failing to provide is sister with an
appropriate medical screening examination; failing to stabilize his sisters emergency medical
condition; and (3) transferring his sister to BARH without first providing stabilizing treatment.
Dismissed on summary judgment.
Ms. Barber sough emergency treatment at RGH she did not appear to have an orderly thought
pattern, had stopped taking her anti-psychosis medications, and had been drinking heavily.
could not be restrained, keep pacing throughout the emergency room, and restraints would place
patient and staff at risk by increasing her agitation. While pacing fell and hit her head
lacerating her scalp, in need of stiches. After getting stiches Dr. Kline found that experienced
some anxiety, disorientation, and speech problems but he attributed that her her psychiatric
problems and alcohol withdraw. Dr. Kline discussed with Dr. Whelan, her 2 year treatin
psychiatrist, and they decided to transfer her to BARH because it had a psychiatric ward. Due to
the result to the blow to her head her brother asked that she be x-rayed, Dr. Kline however
concluded that could safely be transported he did not give her an x-ray. When arrived BARH
they also did not x-ray her head, several hours later started having grand mal seizures and a CT
report done by BARHs emergency department revealed that she had a fractured skull and a right
subdural hematoma and they immediately transferred back to RGH because that hospital had a
neurosurgeon on staff.
2. Issues:
3. Holding/ Reasoning:
a. Summary judgment was granted for the Doctors, because EMTALA does not permit private
suits for damages against the attending physician
b. EMTALA only requires hospitals to apply their standard screening procedure for
identification of an emergency medical condition uniformly to all patients and failed to
offer evidence that RGH did otherwise
1) While the act requires a hospitals emergency department to provide an appropriate
medical screening examination, it does not define that term other than to state its
purpose is to identify an emergency medical condition
2) The plain language of the state requires a hospital to develop a screening procedure
designed to identify such critical conditions that exist in symptomatic patients and to
apply that screening procedure uniformly to all patients with similar complaints - statutes
does not impose on hospitals a national standard of care in screening patients
3) Screen Requirements: provide a screening examination that is appropriate and within the
capability of the hospitals emergency department
4) Because no evidence was offered of disparate treatment, there was no err in granting
summary judgment on the issue
4. Rule:
a. EMTALAs Transfer Requirements: do not apply unless the hospital actually determines that
the patient suffers from an emergency medical condition. Accordingly, to recover for
violations of EMTALAs transfer provisions, the must present evidence:
(1) That the patient had an emergency medical condition;
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(2) The hospital actually knew of that condition;
(3) The patient was not stabilized before being transferred; and
(4) Prior to transfer of an unstable patient, the transferring hospital did not obtain the proper
consent to follow the appropriate certification and transfer procedure
b. The stabilization requirement exists if any individual coms to a hospital and the hospital
determines that the individual has an emergency medical condition thus, requiting actual
knowledge of the emergency medical condition
5. Class Notes:
a) Interesting case because the doctors do treat Baber, they do not turn her away
b) Issue: did the doctors do the appropriate screening
1) Appropriate screening: whatever type of screening they would have done in a similar
situation with a similar patient
c) Should not have alleged EMTALA here, should have just alleged a medical malpractice
claim
d) What does the EMTALA claim get attorney that he might not have had otherwise?
1) It gave them access to federal court that they might not of had otherwise
e) Federal judges have interpreted the language of EMTALA very very narrowly

IV. Class Notes:
A. A reason that a lot of specialty facilities do not accept Medicare is so they do not have to comply
with EMTALA
B. 3 Steps to comply with EMTALA (DUTIES):
1. Appropriate medical screen meants that this indiduval hospital would give meaning that its
nondsparete w/out regard to the medical standard of care (this is from BABER case)
2. Stabilize (or transfer) only applies if its an emergency situation
3. Transferring when unstable (subject to condition to an appropriate transfer)
a. Call the receiving hospital
b. Makes sure there is appropriate personal to treat the patient
c. Send their medical records to the other hospital
C. Who can bring suits under EMTALA?
1) Doctors have obligations under EMTALA but they cannot be sued by the patients
2) Only hospitals can be sued under EMTALA
D. EMTALA REQUIRES:
1. Appropriate medical screening (which is a screening that the hospital would do for any
patients)
2. Stabilize EMC before discharge/ transfer
3. Any transfer of an EMC must be appropriate
E. EMTALA: is meant for catching people when the crash - not meant for long term treatment
1. Do not feel like everything that happens in a hospital emergency room should be turned into
a EMTALA claim
2. EMTALA has made the emergency room the once place where you can go in hospitals that
you cannot be turned away
F. TERMS: are not defined in the statute, but federal judges have defined them relatively narrowly
G. When does the EMTALA obligation end?
1. Once the patient has been admitted into the hospital (a lot of people think this is a very bad
policy call)
2. Reason being is because then the patient can bring a malpractice or other tort remedy

V. Wall Street Journal Article:
Health Care Law
EMTALA
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A. Who are the only people who pay for medical care based on charges?
1. The uninsured
B. Who ends up paying the most?
C. How does EMTALA deal with the problem of people being charged high bills at the emergency
room?
1. It doesnt deal with the issue of who pays for the care when it is given (creates a problem of
balancing out the needs to the patient and the hospital)

VI. Pg. 622: Mrs. Miller Problem:
A. Facts: anesthesiologist at the hospital cannot administer a spinal epidural
B. What claims could Mrs. Miller bring?
1. Against the Hospital:
a. EMTALA: can only be brought against the hospital (there is no private right of action
against the doctor under an EMTALA claim)
(1) What is the EMTALA claim against the hospital? (EMTALA is a statutory cause of
action need to find out what the problem is and how it would fall under one of the 3
areas)
(2) Scope of the damages are going to be an interesting issue pg 611 in the CB tells you
how to cover damages
b. File a malpractice claim against the hospital
(1) If you represent the hospital what might you investigate first in terms of malpractice
liability? (a)
2. Hospital Would Argue:
a. That they are using their normal system
b. Is being about to deliver a baby an emergency medical condition
3. Against the Doctor:
a. Can file malpractice against the anesthesiologist