The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events

Med Care. 2020 Sep;58(9):793-799. doi: 10.1097/MLR.0000000000001360.


Objectives: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation.

Materials and methods: A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year.

Results: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals.

Conclusions: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

Publication types

  • Observational Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Emergency Service, Hospital / legislation & jurisprudence*
  • Emergency Service, Hospital / statistics & numerical data*
  • Hospital Bed Capacity / statistics & numerical data
  • Hospitals, High-Volume / statistics & numerical data
  • Humans
  • Medicaid / statistics & numerical data
  • Ownership / statistics & numerical data
  • Patient Transfer / legislation & jurisprudence*
  • Patient Transfer / statistics & numerical data*
  • Residence Characteristics / statistics & numerical data
  • Retrospective Studies
  • United States