“One problem,” said Hsuan, “is that research indicates that many hospitals violate EMTALA. The harm done by noncompliance often falls on ethnic and racial minorities, especially Black and Hispanic residents of American cities.”

Hsuan and her collaborators interviewed stakeholders throughout the medical system to identify the causes of noncompliance and potential solutions. They identified five main causes ranging from financial incentives to a reluctance to harm the relationships with hospitals that were making illegal referrals—another term for patient dumping. The researchers also identified five potential solutions, including educating sub-specialist physicians and routing hospital transfer requests through the hospitals’ emergency departments.

Beyond EMTALA

Hsuan’s research is not limited to EMTALA. More generally, she studies how emergency rooms can provide the best possible care. She also studies the effects of emergency-room crowding and how to ensure that first responders take patients to the best hospital available.

Research has shown that when patients visit a busy emergency room, they are less likely to receive high-quality care in a timely manner. This is true even for patients with genuine emergencies like strokes, heart attacks, or injuries from a car accident. Additionally, Black and Hispanic heart attack patients are more likely to die when they are taken to a crowded emergency room.

One factor that can lead to differential emergency room care is ambulance diversions. When emergency rooms in an urban hospital becomes overcrowded, the hospital sometimes declares an ‘ambulance diversion,’ which means that no more ambulances can bring patients to that hospital while they clear out the backlog. When this happens, ambulances are routed to other hospitals, and those hospitals’ emergency rooms become more crowded. Sometimes, this leads to a cascading effect where multiple emergency rooms in the same region close at the same time.

Hsuan and her collaborators demonstrated that hospitals are more likely to declare a diversion with fewer patients in their emergency rooms if a nearby public hospital is under a diversion than if a nearby private hospital is under a diversion. Public hospitals treat a higher proportion of lower income patients than private hospitals. This suggests that hospitals may use diversions to avoid treating lower income patients, decreasing the availability of care for lower income individuals.

“One of my goals is to help create more equitable emergency rooms,” said Hsuan. “When people go into emergency rooms, they often have life-threatening problems and are very vulnerable, physically and emotionally. If those people are rejected or marginalized, there is immediate danger to their health. Even when they are not physically harmed by a breakdown in care, the experience can create a lasting sense that, when they were truly in need, the health care system did not care for them. That can affect how and whether people seek health care for the rest of their lives, and it can trickle out to the rest of their community, as well.”