Most hospitals violating EMTALA intend to comply with the law but fall short because of confusion about requirements and competing priorities between doctors and hospitals, according to research led by Charleen Hsuan, PhD, assistant professor of health policy and administration at Pennsylvania State University in University Park.

Hsuan and her colleagues interviewed hospitals, hospital associations, and patient safety organizations to determine how violations occur even though the law should be well understood. In addition to uncovering some of the reasons, they found that the number of EMTALA investigations probably reflects only a portion of the actual number of violations, with those interviewed citing many reasons not to report their suspicions. (An abstract of the study is available online at:

The researchers identified the following reasons hospitals might not comply with EMTALA:

• financial pressure to avoid Medicaid and uninsured patients;

• difficulty understanding all aspects of the act;

• referral burden at recipient hospitals;

• reluctance to report other hospitals to maintain good relationships with those institutions;

• conflicts between physician and hospital priorities.

Physicians sometimes resist accepting patients that they don’t think they can properly care for, citing malpractice concerns, the study says. That can result in an EMTALA violation for which the hospital is most likely to be held responsible.

To address how many of the study’s participants mentioned not wanting to report fellow hospitals to government regulators, Hsuan suggests creating a more informal mediation process.

Financial issues could be addressed by more closely aligning Medicaid/Medicare payment policies with EMTALA, the researchers suggested.