128 Determining Factors Associated With EMTALA Investigations and Citations: For-Profit Hospitals at Increased Risk

Abstract

In 1986 Congress passed the Emergency Medical Treatment and Labor Act (EMTALA). This anti-dumping statute requires medical screening evaluation of patients presenting to an emergency department (ED), stabilization of identified emergent conditions, and, when indicated, transfer for higher level of care. Penalties for EMTALA violation include fines, as well as suspension or termination from Center for Medicare and Medicaid Services (CMS) reimbursement. CMS authorizes investigations of EMTALA complaints and assigns citations when a violation is identified. Previous research demonstrated substantial regional variation in EMTALA enforcement but, to date, nothing is known about hospital-level characteristics associated with EMTALA investigation. The goal of this study is to identify hospital-level features associated with an EMTALA investigation and/or citation. This is a retrospective study examining associations between hospital characteristics and EMTALA enforcement. Observational data on EMTALA enforcement activities between 2005-2013 were obtained from CMS via a Freedom of Information Act request. Hospital characteristics were obtained from the American Hospital Association (AHA). Variables from the AHA include hospital name and Medicare identification number, hospital location (state, rural or urban), hospital size (beds), ownership (eg, for-profit versus not-for-profit), payer mix (eg, proportion of admitted patients insured by Medicaid), teaching status and ED volume. We used multi-variable logistic regression with state and year fixed-effects to estimate the magnitude of associations between hospital features (independent variables) and whether the institution was subject to an EMTALA investigation (dependent variable). Additionally, we evaluated hospital-level features associated with an EMTALA citation among those institutions with investigations. During the study period, CMS completed 4772 EMTALA investigations and issued 2,118 citations. Investigations were conducted at 43% (2,417 of 5,594) of hospitals, and citations issued at 27% (1,498 of 5,594). We observed that hospitals that were large, urban, for-profit, had higher ED volume and treated a greater proportion of Medicaid patients had higher odds of an EMTALA investigation (p<0.001 for each). Odds of an EMTALA investigation were 1.53 (CI 1.15-2.05, p<0.001) higher among hospitals in the top decile of hospital size compared with the bottom decile. Similarly, hospitals with large EDs had higher odds of an EMTALA investigation than smaller ones (OR 2.32 CI 1.69-3.20, p<0.001 for top compared with bottom decile). The OR for an investigation for for-profit hospitals was 1.34 (CI 1.16-1.54) compared with public hospitals. Interestingly, when we restricted the dataset to only hospitals that had an investigation, for-profit status was the only variable that independently predicted receipt of an EMTALA citation (OR 1.51 CI 1.25-1.83). EMTALA is an actively enforced statute with 43% of hospitals investigated and 27% receiving a citation during the study period. However, enforcement activities are concentrated in large, urban, for-profit hospitals. Administrators for such hospitals should be particularly mindful that policies and procedures pertaining to EMTALA are fully developed and adhered to.