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Introduction

In response to a number of widely reported horror stories about emergency rooms turning away seriously ill or injured patients who had no insurance and no money to pay for treatment, in 1986 the United States Congress passed what became known as the Federal Emergency Medical Treatment and Labor Act (EMTALA or the "Act"). This Act is also known as the "anti-dumping" statute. Prior to the 1986 law, there was no requirement on the part of hospitals to treat everyone who came to the emergency room and, in many states, the hospital was not liable for damages caused by the hospital''s refusal to treat a patient. A hospital could choose not to treat a patient who did not have insurance or enough money to pay for the required medical treatment. Sometimes patients would die or suffer serious injuries as the result of a transfer or delay in treatment. To prohibit such patient dumping, Congress enacted the antidumping provisions of the EMTALA.

Liability under the Act

The Act applies to all hospitals which have emergency rooms and which participate in the Medicare program. Almost all hospitals, public and private, receive Medicare funds; therefore, almost all hospitals are covered by the federal Act. The Act imposes two principal obligations on hospitals. First, it requires that when a person seeks treatment at a hospital''s emergency room, the hospital must provide for an appropriate medical screening examination to determine whether an emergency medical condition exists or whether the patient is in active labor. Second, if the screening examination reveals that such an emergency medical condition does exist, the hospital ordinarily must "stabilize" the medical condition before transferring or discharging the patient from the emergency room. Basically, this means that the hospital must make sure that the patient can be transferred safely to another hospital without further endangerment to the patient''s health or, in the case of active labor, the baby''s health.

If a person suffers injury because the hospital did not provide an appropriate screening examination or because it did not stabilize the patient''s condition before releasing or transferring the patient, then that person may hold the hospital liable for money damages based on the violation of the Act. However, the cases that have addressed EMTALA liability have made it clear that the Act is not intended to replace or be a substitute for state medical malpractice liability on the part of the hospital. In other words, the federal Act was not intended to provide a federal remedy for misdiagnosis or medical negligence on the part of a health care provider. It is intended to impose liability only for failure to provide an appropriate screening examination and for failure to make sure the patient is stabilized before the patient is transferred or discharged from the emergency room.

For example, most courts have concluded that an "appropriate medical screening examination" is one that the hospital would have offered to any other patient in a similar condition with similar symptoms, regardless of whether the patient was insured or could pay for the medical screening. Thus, it has been said that EMTALA is violated only when individuals, who are perceived to have the same medical condition, receive different treatment. It is the patient''s burden to establish that the hospital treated him or her differently from other patients. Some courts have determined that, in order to prove that he or she did not receive an appropriate medical screening examination, the patient must establish that there was an improper motive on the part of the hospital. That is, that the decision as to what type of screening to provide was motivated by improper factors such as indigency, race, or the sex of the patient. The majority of courts, however, have concluded th at there is no such "bad motive" requirement. They hold that the patient simply must show that he or she was treated differently from other patients. So far, the United States Supreme Court has not expressed an opinion as to whether the "bad motive" interpretation of the appropriate screening requirement was contemplated by the drafters of the Act. The Supreme Court has recently ruled, however, that there is no such bad-motive requirement to establish that a hospital has failed to adequately stabilize a patient before transferring or discharging.

Therefore, if a hospital provides appropriate screening and determines that the patient has an emergency condition (or is in active labor), the hospital must make sure the patient is stabilized before transferring or discharging. The Act defines "stabilize" to mean that the hospital must provide such treatment necessary to assure that no material deterioration of the condition is likely to result from or occur during the transfer. It has been held that once the hospital undertakes stabilizing treatment for a patient who has arrived with an emergency condition, the patient''s care then becomes the legal responsibility of the hospital and the treating physicians. At that point, the adequacy of care is not governed by EMTALA but by state law governing medical malpractice.

For example, in one recent case, a federal appeals court held that a hospital''s alleged negligence in deciding whether to transfer a seriously injured patient to a long-term care facility was not governed by the EMTALA where the patient had been admitted to the hospital and was treated there for some 12 days before the decision was made that she was stable enough to transfer. When she was transferred to the other facility, her condition rapidly deteriorated, and she died. In ruling that the screening and stabilization provisions of EMTALA did not govern, the court reasoned that the stabilization requirement was intended only to regulate the hospital''s care of the patient in the immediate aftermath of the act of admitting her for emergency treatment, and it did not govern the duties owed by the hospital once she was admitted to the hospital and placed under the care of physicians there. Once that happened, state medical malpractice law governed the actions of the hospital and doctors in their decision whether to transfer her to another facility.

Conclusion

The antidumping provisions of EMTALA have added important elements to a patient''s rights when he or she seeks treatment at a hospital emergency room. A hospital can no longer simply turn a patient away if he or she has no money or no insurance to cover the treatment in the emergency room. The hospital must at least give an appropriate screening and sufficient treatment to stabilize the patient before transferring or discharging. Persons who feel they have suffered injurious treatment at hospital emergency rooms because they did not receive the same type of screening or treatment that other similarly injured or ill patients would have received should seek the advice of an experienced attorney.