Monday, May 12, 2008

The wreck of the good ship, EMTALA

Physician-blogger Edwin Leap has some pertinent observations about the EMTALA law and the so-called unintended consequences. Here are a few excerpts:
EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren't familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being 'dumped' on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.

For those of us who practice emergency medicine, and by now any medicine in a hospital that accepts Medicare payments, no one can be turned away for financial reasons. ...[S]urgeons, neurologists, cardiologists, otolaryngologists and just about every other 'ist' is burdened with the same issue. The people they see in the ER, admit to the floor, or take to surgery or the cardiac cath lab will frequently be unable to pay anything, but then still be able to sue for millions of dollars. It's hard for specialists to run practices when large numbers of patients pay nothing for their care. I understand their issues here. I don't blame them a bit for being angry.

...Across America, small and medium sized emergency departments and hospitals are closing. Trauma centers and teaching hospitals are struggling and overwhelmed. And specialists are simply leaving hospital care in order to avoid being on call, and the attendant EMTALA responsibilities that call entails. They’re working in surgery/outpatient centers. They’re leaving the setting where they are compelled to give care away, and where they are constantly overwhelmed by more and more demand, less and less payment.

...But here's the final irony. EMTALA has created the very conditions it sought to avoid. Now, with specialists unavailable, hospitals full, transfers always difficult and no lack of genuinely sick and dying patients, there’s often 1) no one to care for them and 2) no place to put or send them. EMTALA, the federal mandate to save the poor from sickness has begun to crumble at its foundations, and leave untold numbers of patients, poor and paying, without care.

...You might make the argument that nationalized health-care can fix this with money, but as we see in so many problems, money doesn't do much. Money in the school system still leaves us with staggering drop-out rates and high-school illiteracy. Money, in the hands of an irresistible, un-yielding, entitlement crazy, grandiosity-leaning government system will probably result in an even greater disaster than EMTALA.

My suggestion? Get the government out of it all. If you do, the poor will likely get better care, since we'll be able to screen out and turn away those who abuse their privilege. And doctors, that pesky, generally unimportant part of the medical equation, will actually return to hospitals and be available; out of a sense of duty, professionalism, entrepreneurial spirit and genuine compassion without federal compulsion.
His points are all good ones. They are all consequences of the fact that forcing doctors to provide free care is just a form of theft and/or slavery.