1. EMTALA Anti-dumping Update
Uninsured Audioconference
March 5, 2008
Charlotte Yeh, MD, FACEP
Regional Administrator, New England, Region I
Centers for Medicare & Medicaid Services
JFK Federal Building, Room 2325
Boston, MA

3. So Where are We Today?
History of EMTALA
In the early 1980’s, reports of widespread “patient dumping” began to appear in the press and the medical literature.
Schiff et al. (1) estimated that 250,000 inappropriate transfers of medically unstable patients occurred in 1986, resulting in increased patient morbidity and mortality.
Schiff RL, Ansell DA, Schlosser JE, et al: Transfers to a public hospital, a prospective study of 467 patients. New England Journal of Medicine 314: , 1986
History of EMTALA- TPs
Less money from these insured patient groups was available to “cost shift” to pay for indigent care.
Treating nonpaying patients became increasingly financially burdensome.
It was believed that many private hospitals were transferring patients to the streets or dumping them on public hospitals before they had adequately diagnosed or stabilized these patients’ emergency medical condition.

4. CMS EMTALA Enforcement Data
National Data
FY 04
FY 05
FY 06
# Complaints
658
738
744
# Surveys
616
649
642
% with Violations
30%
38%
40%
Enforcement:
Complaints trigger an investigation.
No complaints = no investigation.

5. FY 06 Enforcement Actions Putting EMTALA in Perspective
642 surveys
40% substantiated (258)
Hospital/CAH Complaint
Surveys
4,743 surveys
3.1% substantiated at condition-level (147)
27% substantiated deficiencies at any level (1281)
Number of hospitals nationally= 4,927
EMTALA Enforcement Data
Is there objective evidence of widespread variation among the RO’s in EMTALA enforcement?
ACTS data provides insights, but no conclusive answers

6. Regional FY 06 EMTALA Complaint Volume
RO RO
RO RO
RO RO
RO RO
RO RO
National Total: 744

7. Regional FY 06 EMTALA Complaint Rates*
RO % RO %
RO % RO %
RO % RO %
RO % RO %
RO % RO %
National Rate: 12.1%
* Rate = # Complaints divided by # Hospitals
Regional FY 06 EMTALA Complaint Rates
Regional rates relatively stable over time, except for RO’s with fewer hospitals
Within regions, state complaint rates vary more over time
Smaller numbers at the state level magnify small changes in complaint volume

8. State Complaint Rates
Only 1 State had consistently high complaint rates over time:
FY 04 FY 05 FY 06
State A 83.7% 97.0% 92.1%
State A had 3.9% of all US hospitals in FY 06, but 29.8% of all EMTALA complaints
Florida has a total of 239 hospitals.

9. 2006 EMTALA Data for California and Florida
Total Hospitals
419
239
Total Complaints 10
220
Disapproved Investigations 49
Approved Investigations
171
Percent Approved
100%
78%
Substantiated 8 40
Percent Substantiated
80%
23%
Terminated

10. What does this data tell us about enforcement consistency?
Since EMTALA enforcement is complaint-driven, a major source of regional variation is beyond CMS control
Regional and state variation in the rate of EMTALA complaints causes different levels of enforcement activity

11. Source of FY 06 Complaints
Patient/family %
Self-report %
Other provider %
Staff %
CMS %
Other %
Total * %
* Total ≠ total complaints. 10 states had 22 more sources than complaints; 14 states identified no source in 91 cases.
Selection of Complaints for Survey
Is there evidence of variation among regions in authorizing surveys in response to EMTALA complaints?

12. Distribution of FY 06 EMTALA Allegations & Violations
(N=1349) (N=473)
Overall % %
On-call % %
Screening 26.2% %
Delay % %
Stabilization 20.0% %
Transfer/dis % %
Recipient Hospital 8.2% %
Signage % %
Log % %

13. CMS Enforcement Data
Since inception of EMTALA 13 hospitals have been terminated from Medicare.
What does this data tell us about enforcement consistency?
Regions vary in the % of complaints authorized for survey, but in all regions most complaints recommended by SAs are investigated
Some RO’s may be more selective in authorizing surveys in states with higher complaint rates, but no clear pattern across RO’s
Variation within RO’s suggests the facts of each complaint are reviewed
What does violation data tell us about enforcement consistency?
Substantiation rates vary among regions
Available data doesn’t tell us the source(s) of the variation
Due to small numbers, in some regions rates can be misleading – a few changes in survey results make a big difference
The highest volume RO’s have the lowest substantiation rate
Otherwise, no obvious correlation with complaint rates, source of complaint or authorization rates to consistently explain the differences in substantiation rates

14. Regulatory Enforcement Process:
OIG
2006
21 cases resulting in $715,000 in recoveries
2005
18 cases resulting in $455,500 in recoveries
2004
21 cases resulting in $535,000 in recoveries
2003
28 cases resulting in $737,000 in recoveries
2002
22 cases resulting in $501,000 in recoveries

15. What does this data tell us about enforcement consistency?
Distribution of types of violations generally correlates with distribution of allegations
Reinforces that EMTALA enforcement is complaint-driven
Screening, stabilizing treatment, & transfer are the big problem areas
CMS enforcement is not focused on administrative violations

17. Evolution of EMTALA 1985 - EMTALA enacted (42 U.S.C. §1395 dd)
Statutory “enhancements”
More statutory “enhancements”
Interim final Regulations
Interpretive Guidelines
Special Advisory Bulletin
OPPS Regulations
OPPS Q&A
CMS Guidance Letters, Proposed Regulations
Final Regulations
S/C Guidance Letter
Medicare Modernization Act
Revised Interpretive Guidelines
– EMTALA TAG
Updated S/C Guidance Letters