Emergency department (ED) utilization has risen steadily over the past 20 years, in part
because patients are guaranteed medical attention under the Emergency Medical Treatment
and Active Labor Act (EMTALA). EMTALA requires EDs to evaluate and stabilize all
patients regardless of ability to pay, and hospitals must provide specialist care or arrange
transfer to a tertiary care center when specialist care is unavailable.1,2 Community hospitals
have reported difficulty providing specialist coverage since the enactment of EMTALA, and
the Centers for Medicare and Medicaid Services (CMS) published its “Final Rule” regarding
EMTALA in September, 2003, stating that hospitals with EDs are not required to guarantee
specialist coverage at all times.3
It has been suggested that elimination of coverage requirements permits selective transfer of
underinsured patients to centers with mandatory on-call specialists.4,5 This concern has not
been validated, in part because data regarding EMTALA referrals are limited. Our
institution has kept a log of transfer requests since 2000 that provides a unique opportunity
to analyze trends in EMTALA transfer patterns.