The Spatial Patterning of Recent Emergency Medical Treatment and Labor Act Violations in the United States

The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 requires Medicare-participating hospitals to provide medical examination screenings to patients in emergency situations, regardless of their ability to pay, and prohibits the transfer of patients under these circumstances, unless essential or requested. This study examines spatial clustering of EMTALA violations between 2016 and 2022 and identifies the characteristics of violating hospitals.

We linked Centers for Medicare and Medicaid Services data on EMTALA violations with hospital-level variables (bed size, ownership type, system affiliation, and Disproportionate Share Hospital status) from the RAND data set. To assess the degree and type of clustering among counties containing hospitals with more than or equal to 1 EMTALA violations, we applied Local Moran's I tests.

From 2016 to 2022, there were 3,889 deemed EMTALA violations at 1,144 hospitals within 800 counties across all 50 states. The most common violations were failure to comply with antidumping provisions and failure to conduct a medical screening examination. Characteristics of violating hospitals included for-profit status, multiple ownership changes since 2016, Disproportionate Share Hospital status, and urban location. Per our spatial clustering analysis, EMTALA violations were highly clustered among affiliated hospitals within health systems across the west, southeast, and northeast.

This study examines characteristics of hospitals with deemed EMTALA violations, including multiple ownership changes and system affiliation. Hospitals with EMTALA violations were spatially clustered concentrated among system-affiliated hospitals. In terms of policy, greater alignment between Medicare and Medicaid payment policies and EMTALA may offset hospitals' incentive to avoid "unprofitable" patients, thus reducing violations.