The Hidden Cost of EMTALA
Why A Law Meant to Guarantee Care Can Actually Prevent It
In my practice as an emergency physician, I often encounter cases of a condition known as choledocholithiasis. (A mouthful, to be sure.) This disorder describes a gallstone which has escaped the gallbladder and has become lodged in the bile ducts of the liver, causing blockage. It is extremely painful and, if untreated, creates substantial risk of life-threatening infection of the bile ducts. The treatment is complicated; surgically removing the gallbladder is not enough, as the offending stone must be retrieved and the duct blockage relieved. This requires a highly specialized scope procedure called ERCP (Endoscopic Retrograde Cholangiopancreatography, for those looking for new Scrabble words).
ERCP can only be done by gastroenterologists who have undergone extra training in advanced endoscopy, and only at hospitals where equipment and facilities can support this procedure. In other words, it is not something that can be done at my small rural ER, or even at many large hospitals. When I see such a patient in my small emergency department, I can make the diagnosis, but I can do little to help the patient beyond administering pain and nausea medications. I must transfer my patient to a hospital capable of performing ERCP.
The Transfer Process
The transfer process entails prolonged phone negotiations with tertiary care centers which are already overburdened with patients. Physicians and staff spend hours, sometimes even days, securing acceptance for patient transfer. This delay is compounded by the necessity of arranging appropriately staffed ambulance services. (Not all emergency departments or hospitals have the same capabilities, and similarly, neither do all ambulances.)
Take the case of the gallstone lodged in the bile duct, for which ERCP must be performed in a timely fashion to prevent life threatening infection. After the diagnosis is made, I begin calling the nearest large hospitals capable of treating the condition. I do not speak directly to another physician— these hospitals have transfer centers manned by clerical support staff. I relay the details of the case to whomever answers the phone at the transfer center. That person tells me that he will confer with a physician on duty and relay the results of the lab work and imaging tests I have presented. Several hours go by while this happens, and the transfer center representative will then call me back with whatever decision has been made.
If my patient is lucky, I am told that the patient is accepted for transfer to the large hospital’s emergency department, and I can begin making calls to local medical transport companies to find a suitable ambulance. Sometimes, I am told that the hospital declines transfer, and I begin the process again with the next hospital on my list. Most commonly and also most frustratingly, however, I will be told that the patient is accepted for transfer but that there is no bed presently available at the receiving hospital, and that the patient will be put on the waitlist, and we will be called back when a bed is available.
Paradoxical Delays
Once the patient lands on the dreaded waitlist, there is no end in sight. The receiving hospital will not give me any estimate as to how long the wait may be and will not even clarify whether it is a matter of hours versus days. For my poor patient who needs the ERCP, it is often days. I have encountered delays of more than a week. The patient will ask normal, reasonable questions of their doctor, such as, “when will I be transferred?” or “when will I have the procedure?” The frustrating answer I must give to most of these questions is usually, “I don’t know, I’m sorry.” “Is it going to be today? Tonight? Tomorrow?” “I don’t know, I’m sorry.”
Why is this happening? Why is my patient stuck in an emergency room that cannot treat his emergency? The reason is not as simple as hospital overcrowding. It has quite a lot to do with a law known as EMTALA.
EMTALA
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, was designed to guarantee that no patient is denied emergency medical attention regardless of their ability to pay. This federal law mandates that hospitals receiving Medicare funding must evaluate anyone seeking treatment for a medical condition and must stabilize any patient found to have a medical emergency. EMTALA’s foundational principle—that we must not idly allow vulnerable patients to suffer from medical emergencies—is universally agreeable. As my gallstone patient demonstrates, however, the law’s practical implementation is fraught by unintended consequences.
EMTALA was originally passed in response to the practice of "patient dumping," where hospitals either refused to treat or diverted uninsured or underinsured patients to other facilities so as not to incur the costs of providing unreimbursed care to patients who could not pay their bills. The law aimed to address this by ensuring that all individuals have access to emergency medical services. Despite its well-intentioned origins, EMTALA's rigid requirements can inadvertently harm the very patients it seeks to protect. Every single shift in the ER, I encounter dangerous delays in patient care directly attributable to EMTALA.
My gallstone patient is but one example of a scenario happening constantly, all over the country. A patient arrives at a small, rural ER with a complicated medical emergency. The local ER, though staffed with skilled emergency physicians and nurses, simply does not have the necessary facilities, medications, tests, treatments, or specialists to provide the care the patient needs. However, EMTALA's requirements prevent the diversion of such patients with instructions to seek care at a more equipped tertiary care center. Instead, the law mandates that the patient must be evaluated and stabilized in the local ER and then transferred through an official process. The irony is that, in many cases, it would be faster and safer to advise patients to drive or be driven to the nearest tertiary care center equipped to handle their condition. However, doing so would constitute a technical violation of EMTALA, exposing the referring physician and the hospital to legal repercussions.
Even though the patient is stuck in my ER on a waitlist because the large hospital is full, had the patient decided initially to go to the larger hospital’s ER, EMTALA stipulates that the large hospital is not allowed to turn him away, and must treat him no matter how busy they are. I cannot advise my patient to leave my ER and go to the one capable of treating him, as I would be breaking the law. Ironically though, if my patient were to decide, of his own accord, to sign out against medical advice from my care and have his family drive him, he would get his procedure done much faster than by waiting for me to go through the official and putatively safer process to transfer him by ambulance.
Well-intentioned government interventions can inadvertently create significant tradeoffs and unintended consequences. While EMTALA seeks to guarantee that all patients receive essential emergency care, it paradoxically hampers timely treatment, as seen in the cumbersome transfer process for patients needing specialized procedures. The law’s stipulations, and the bureaucracy that has grown up to fulfill them, often result in prolonged suffering and potential harm. The unseen tradeoffs of government regulation manifest in the paradoxical bind whereby physicians, entrusted to make life-altering decisions, are hampered from executing the most logical and expeditious course of action for their patients. EMTALA, while noble in its intent, confines the very patients it seeks to help within a bureaucratic labyrinth that often delays critical treatment. The consequence is a system where the so-called safety net can also become a snare, hindering patients from receiving the care it supposedly guarantees.