As a conservative, small “l” libertarian, systems and process analyst. I have authored many position statements and white papers on everything government.  His multiple political campaigns have provided impetus for a wonderful “sand box” of improvement opportunities

Known for thinking outside the box and offering solutions that often overlooked. This is his latest foray into government interference in business. Healthcare is a necessary evil, government involvement in the segment makes it very unprofitable.

The concept in the following document can be used by hospitals, for profit, non-profit, teaching or community to stop losses brought by EMTALA and ACA.

This document available here in ppt format.

Evolving ER Care


Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).  It requires participating hospitals to provide emergency health care treatment to anyone needing it regardless of citizenship, legal status, or ability to pay. The statute defines “participating hospitals” as those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program EMTALA’s provisions apply to all patients, not just to Medicare patients. Emergency care required by EMTALA is not directly covered by the federal government. The law has been criticized by some as an unfunded mandate.

American Hospital Association (AHA) reports uncompensated care (bad debt and charity care) at 6.1 % in 2009.  AHA Chartbook 2011, chapter 4 slide 7

Patients treated under EMTALA may not be able to pay or have insurance or other programs pay for the associated costs but are legally responsible for any costs incurred as a result of their care under civil law. The hospital is allowed to determine that there is no emergency, using their normal screening procedure, and then refuse EMTALA treatment.

Benefits of the Affordable Care Act (ACA) include:

  • Improving Quality and Lowering Healthcare Costs
  • Free preventive care
  • Prescription discounts for seniors
  • Protection against health care fraud
  • Small Business Tax Credits
  • New Consumer Protections
  • Pre-existing conditions
  • Consumer Assistance
  • Access to Healthcare
  • Health Insurance Marketplace.
  • Benefits for Women
  • Providing insurance options
  • Covering preventive services
  • •Young Adult Coverage
  • •Coverage available to children up to age 26
  • •Strengthening Medicare
  • •Yearly Wellness Visit
  • •Many Free Preventive Services for some seniors with Medicare
  • •Holding Insurance Companies Accountable
  • •Insurers must justify any premium increase of 10% or more before the rate takes effect

Timeline of Health Insurance Marketplace

  • October 2013 – Open enrollment begins
  • January 2014 – Coverage begins
  • March 2014 – Open enrollment closes

EMTALA and ACA are incompatible statutes

  • EMTALA mandates hospitals treat anyone in need regardless of status or ability to pay.
  • ACA does not relieve that mandate.
  • ACA reduces funding for Disproportionate Share Hospital (DSH) funding  by 75%.
  • Health Care and Education Act, Public Law No. 111-152, section 1203
  • Reductions rely on the theory that ACA mandates individuals purchase health insurance and as result hospitals will treat fewer EMTALA patients.
  • Hospitals are faced with choice of absorbing more costs or violating EMTALA under threat of penalty.

EMTALA and ER Care

EMTALA requirement

  • Hospitals and providers must evaluate, stabilize and provide basic lifesaving treatment to any patient who comes to an emergency department or is in active labor.
  • Hospitals and providers are not allowed to let a patient’s ability to pay to be considered during emergency care.
  • Evaluate
  • A medical screening examination to determine if an emergency exists.
  • Treatment
  • Treatment for any emergent condition until stabilization.
  • Stabilize
  • Safe discharge or a safe transfer to an appropriate facility.

Paradigm Shift in ER Care

Traditional ER Process Flow

  • Point of Entry – Walk-In or EMS
  • Fill the Bed
  • Medical Screening Examination
  • Prioritization and Registration
  • Stabilization, admit, discharge or transfer
  • Higher cost per transaction

New Paradigm ER Process Flow

  • Point of Entry – Walk-in or EMS
  • Medical Screening Examination
  • Prioritization and Fill the Bed
  • Registration
  • Stabilization, admit, discharge or transfer
  • Lower cost per transaction

Change in Process Flow

Point of Entry


  • Pre-screening by RN
  • Assign Bed Type
  • Exam, Treatment or Acute Care
  • Examination
  • Registration
  • Treatment and Stabilization


  • Pre-screening by EMS and RN
  • Assign Bed
  • Examination
  • Registration
  • Stabilization, admit, discharge or transfer

Walk-In Care Path

Pre-screening by RN

  • Immediate care assigned to exam room

    • Minor illnesses and preventative care services
    • Care by Nurse Practitioner
  • Urgent care assigned to treatment room
    • Illnesses and injuries requiring immediate care
    • Care by Physicians Assistant
  • Emergent care assigned to acute care room
  • Immediate care – Nurse Practitioner
  • Urgent Care – Physicians Assistant
  • Emergent care – Physician and nursing staff

Ambulance Care Path

Screening by EMS

  • Resuscitation (trauma, cardiac arrest, heart has stopped)
  • Emergent (life or limb threatening, chest pain, stroke)
  • Urgent (abdominal pain)
  • Non-urgent (broken arm)
  • Secure care / Mental Health Intervention