EMTALA dates from what, the mid 1980s. Didn't you
know about it when you were choosing your specialty? Knowing about it, why did
you choose a specialty where you're most likely to be hit hardest by
My answer was long and rambling and you may read it if you wish, but the easy answer is that Emergency Medicine interested me and was the best fit for my inquisitiveness and short attention span. Jack of all trades master of none. That's me.
Here I would like to compile a list of the unintended consequences of the unfunded federal mandate called EMTALA. To my nursing and physician colleagues please add to the list as you see fit.
My primary objection is voiced much more eloquently at "Movin' Meat" (click title above to see his EMTALA post) and is, essentially, that EMTALA is nothing more than theft by legislative fiat. Under penalty of law we MUST see all patients with an "emergency condition" or face jail or financial loss. It does not apply to dentists, chiropractors, massage therapists, aromatherapists, shamans etc... Here is my short list of what flows from this communistic scheme...
1. Cost Shifting: Medical treatment has cost. Someone pays. EMTALA has shifted the burden of payment for the uninsured onto the insured, taxpayers, insurance companies, and doctors. As a result, it's harder to get insurance, our taxes go higher, the number of uninsured has skyrocketed, insurance rates have skyrocketed, and doctors make less money. I know, poor rich doctor right? I'm 46 and finished paying off my school loans five years ago. If I keep at this for another 15 years I can retire comfortably (unless I screw up at work and get sued). If you want to get rich and sleep well then stay the hell away from medicine. If you want to work in a tremendously demanding field with high pressure, responsibilities that increase every year, and pay that does not keep pace with inflation then medicine is perfect for you!
2. Insurance Tomfoolery: Since I don't work in the insurance industry I will only say that with my current insurance a medicine that I take daily costs $90 per month cash and $93 per month with my insurance. My taxes, even with the "Bush Tax Cuts" are 33% of my income. I work harder and faster for less money every year, and, when I find an out to a less taxing (in all senses) profession I will take it. I am not alone.
3. Physician Shortages: Speaking of doctors leaving the profession lots of irreplaceable talent in medicine is opting out of the system. Surgeons train for AT LEAST five years, and that's just to do general surgery. Their debt load out of residency can approach $300,000. To do a surgical sub-specialty add $100,000 of debt, a divorce or two, and three more years in the black hole. You can replace an office manager by posting an ad on Monster.com, you can not replace a neurosurgeon or cardiothoracic surgeon if no one is willing to go through residency hell. In other words, these fine humans have to, at least at some point, believe that the sacrifice will be worth it and not just in financial terms.
Now, with EMTALA, specialty surgeons are dropping their hospital privileges like hot potatoes and opening up surgical centers. I don't blame them, if they sign on with a hospital then they have to take ED call and any drunk asshole who falls off a bar stool and breaks his leg at 3am on a Sunday has just blown the whole day for the orthopedist on call. All his paying patients are bumped from his schedule so he can take care of the patient in the ED. I live in a town of 200,000. We have five orthopedic surgeons. Five years ago we had six. Next year we will have four.
We do, in fact, have three plastic surgeons in town. None will maintain privileges at the hospital. So now your complicated ear laceration will be repaired by, well, me. I'm not bad, but I'm no plastic surgeon.
Interventional cardiologists? We have one. We have been trying to recruit another for three years. No one will come here because of the Emergency Department and the burden it would place on them to give away care. How much is it worth to save a patient dying from a heart attack? The answer is a number greater than zero, really, it is.
4. Increased Demand for ED services: The uninsured public has learned over the years that the ED is free (and that you don't have to be a US citizen to take advantage of it). What I mean is that when they are treated in the ED they get a bill which they never pay. Since they have no money and no credit there is no way to collect and no consequences for using the EMERGENCY DEPARTMENT as the "SNIFFLE AND WORK EXCUSE DEPARTMENT". Our collections, a bit below average for Emergency Departments across the country, are about 28 cents on the dollar.
5. Encouragment of Personal Irresponsibility: Because the uninsured public has come to rely on the free care we provide their health maintenance needs are not met. Consequently I often see patients whose untreated hypertension has resulted in a stroke or heart attack. Often there is no one to blame here but the patient and EMTALA. If you had to choose paying a few hundred dollars a year to see your Internist or FP to manage your chronic medical conditions AND you had to pay for your medicine wouldn't it be really easy to fall into thinking that it doesn't matter really because if you get into trouble you can just go to the ED? Believe it or not this truly is the way people think. If you doubt me just look at the number of people who still smoke and don't give me any crap about "evil tobacco companies". People choose and at least in the ED they have usually chosen poorly. Who should pay for this? EMTALA doesn't say and its silence is deafening.
6. ED Overload: Because the ED is the place of first and last resort now for huge numbers of uninsured we physicians are battered by the need to sort through piles of the unsick so that we don't miss anyone who truly has an emergency. In our ED we saw 70,000 patients last year. It was renovated in 1990 to accommodate 25,000 patient per year. Oh, and by the way, you better not miss anything in one of the "unsick" or you will get a letter from an attorney, or, what's often worse, a patient complaint.
7. Nursing Shortages: Because of the now ridiculous demands of the ED, nurses are fleeing. They are not paid on a production basis. They are not supposed to have more than a few patients at one time and they are supposed to focus on the patients they have. The nurses save our asses time and again because they have good clinical judgement AND they spend a lot more time with our patients than we do. It is routine now at my institution to lose a nurse a month and, if they can be replaced, they are replaced by newbies. The only way to make the ED work now is for nurses to cover each other and see each other's patients while they do all manner of extraneous tasks (patient transportation to the floor for instance). I wouldn't work one day in the ED as a nurse. It's unsafe. Congratulations voting public, your government representatives have legislated you into a "guinea pig for newbie nurses" status at many of our EDs. Now before I get a lot of hate mail from nurses let me be the first to say that there are many great newbie nurses out there, but that all of us need to learn to drink from the fire hose that is the ED under supervision.
8. Health Care as a Right: EMTALA, like all the other wonderfully successful government entitlement programs has, WOW, produced a sense of entitlement in the uninsured! As a direct result of EMTALA many people who can least afford to get sick do not think it is their responsibility anymore to either make good choices about their health or pay for the consequences of their bad choices.
9. Bad Math: EMTALA says 2 does not equal 2. You see, because of the need to cost shift, doctors are now payed based on government and insurance company fee schedules. These basically say that a $900 procedure is reimbursed at, say, $250. Now that's new math! I am looking forward to the application of EMTALA to the auto industry so I can finally buy a BMW.
10. Bureaucratic Asexual Reproduction: Lots of full time government jobs created to police EMTALA. Lots of lawyers happy. Lots of politicians elected for giving away other people's stuff. It's easy, after all, to give away other people's stuff, especially those pretentious, rich, selfish doctors. Many of my patients do not deserve the care they get on the back of the taxpayer, but as William Muney (Clint Eastwood) says in Unforgiven, "Deserving's got nothin' to do with it."