Dipping the Drivers License into EMTALA’s Can of Worms

Sean Scorvo, MD

Please allow me the driest lead-in sentence imaginable for an article: EMTALA (the Emergency Medical Treatment and Active Labor Act) is part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986.  I apologize for that…I suppose I should explain the reasoning for my milquetoast moment.

The law’s goal was to prevent the day’s common “wallet biopsy” practice wherein one of the first questions asked upon a person’s Emergency Department arrival, or an ambulance’s report  was “do you” or “does the patient” have insurance?.  If the person didn’t have insurance, or if they just couldn’t prove it, the person was frequently advised to go to another hospital.  While this saved the hospital money, the delay in treatment sometimes cost people their lives or exacerbated the condition they were seeking care for.  Thus, the short story is, EMTALA saves lives.  However, things are never quite so simple as they seem and, as you might have guessed, where there is a short story, a long story and a proverbial Can of Worms isn’t far behind.

The long story is that EMTALA makes Emergency Departments a hotbed for fraud, and loses money for the Emergency Department.  The latter point is multifactorial, but the former point is surprisingly straightforward.  Let us assume you aren’t one of our nation’s fine, upstanding citizens.  You may not be able to quote EMTALA, but you’ve been around long enough to know that the Emergency Department has to see you regardless of whether you bring a valid ID.  You’ve taken this a couple steps further on subsequent visits, given a fake address, and found that the bill never arrives.  Putting two-and-two together, you come to see the Emergency Department as your center for free healthcare and controlled substances such as vicodin so long as you stay one step ahead by using a different name and address, and switching up facilities now and then.  Sound far fetched?  Consider that Emergency Department patient registration analysis consistently shows fraudulent identity & address use between 5% and 15% even after controlling for factors such as homelessness rates.  So, the question is: “Is there a balance that can be struck between EMTALA compliance and fraud prevention?”

In an attempt to tip the scales back to level, some Emergency Departments have started to require some sort of picture ID as a pre-determinant for the receipt of controlled substance prescriptions (vicodin, percocet, valium, etc.)…”no drivers license, no vicodin” is the mantra.  The logic in those Emergency Departments is that fraud is frequently tied to drug seeking behavior, and there is certainly no faulting that logic as the link is solid.

My Significant Other’s 18 year old daughter, hearing me talk about this one day, dug out of her purse not one, but two fake IDs to show me “…how easy it is to get a fake ID.”  Refraining from the “what is she doing with the fake ID” issues this raised with her mother and me for a moment , it turns out she was able to purchase the ID she now allows me to use in my identity fraud demonstrations for $15 (she knew a “guy” who knew a “guy”).  It has holograms, functioning barcodes, and even lists her as an organ donor (apparently there are some ethics to the endeavor).  I’d like to post a picture of it here, but I can assure you, I would become person non grata in this household rather quickly if I did – “Kinda-Daughter” would rapidly revoke my “Kinda-Daddy” status.

The point to this digression is that requirement of a picture ID in order to receive controlled substances from the Emergency Department is an easily surmountable barrier for a person with a prescription drug dependency, a person getting prescription drugs to turn around and sell on the street, or a person in pursuit of some other fraudulent endeavor.  The recording of the picture ID, however, IS an additional task for an already overburdened hospital/clinic staff…and time spent on the task costs us all extra $ in the form of premiums, etc.

In short, EMTALA is still a necessary Can of Worms…though that isn’t to say there aren’t better Lids to put on the proverbial Can. (There are).

Sean Scorvo, MD is an Emergency Physician and President of Middlegate Med in Gresham, OR.