Project Summary The Emergency Medical Treatment and Labor Act (EMTALA) is one of the most important pieces of federal legislation governing emergency care. EMTALA was passed in 1986 in response to highly publicized incidents of inadequate, delayed or denied treatment of uninsured patients by emergency departments (EDs). The intent of EMTALA was to prevent EDs from practicing patient “dumping,” defined as turning away or transferring patients without authorization or initiation of appropriate stabilizing measures based on their ability to pay. EMTALA requires that all ED patients receive a timely medical screening evaluation, stabilization of identified emergent conditions, and, when indicated, transfer to another facility for higher level of care. EMTALA is an actively enforced law. EMTALA empowers the Centers for Medicare and Medicaid Services (CMS) to authorize EMTALA investigations and grants substantial punitive powers. Since 2005, 43% of U.S. hospitals have been investigated and 27% cited for EMTALA violation. There is 5-fold variation in rates of EMTALA citations across CMS regions. It is unknown whether this variation reflects arbitrary differences in reporting, investigation and enforcement of alleged violations, or true differences in quality of care. Little is known about characteristics of hospitals cited for EMTALA violations or how facility response to citation impacts access to care for patients served by the institution. To evaluate whether EMTALA enforcement serves as a viable tool to reduce health disparities and promote quality we propose to (1) create a longitudinal dataset of EMTALA citations 2005-2016 linked to hospital characteristics and quality of care measures, (2) use multivariable logistic regression models to evaluate the associations between facility-level features (e.g., payer mix, hospital quality, ED volume, urban/rural status) and citation for an EMTALA violation, and (3) survey hospital administrators to explore facility response to EMTALA citations. We will conduct an exploratory survey of administrators at California hospitals with recent EMTALA citations (2014-2016, n=96) to characterize and describe operational changes following citations. We expect facilities to respond to EMTALA citations with a variety of measures including modification of on-call specialist coverage, overhauling policies and procedures, educating providers, auditing procedural compliance, and instituting other important but resource intensive measures including hiring additional ED providers, opening beds, or upgrading facilities. Understanding whether EMTALA citations disproportionately impact facilities with poor quality, or hospitals serving vulnerable populations, and how facilities respond to EMTALA citation will improve understanding of how EMTALA impacts access to emergency care for vulnerable populations. EDs are an essential part of the U.S. safety-net, and the provider of last resort for millions of underserved low-income and minority patients, making this issue of particular importance to the AHRQ priority populations.

Project Narrative The Emergency Medical Treatment and Labor Act (EMTALA) is the most important federal legislation governing emergency care, as EMTALA citations can result in CMS provider agreement termination and lead to hospital closure. Currently there are no published studies examining predictors of EMTALA citation or how facilities respond to citation. Understanding whether EMTALA enforcement disproportionately impacts facilities with poor quality, or hospitals serving vulnerable populations, and how facilities respond to EMTALA citations will help to elucidate whether EMTALA enforcement serves as a viable tool to reduce health disparities and promote quality.