Editing Emergency medicine (section)

==Financing and practice organization==
{{Globalize section|the United States|date=August 2020}}

===Reimbursement===

Many hospitals and care centres feature departments of emergency medicine, where patients can receive acute care without an appointment.<ref>{{Cite web|url=https://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine/|title=Definition of Emergency Medicine|website=Clinical & Practice Management|publisher=American College of Emergency Physicians|access-date=16 November 2016|archive-url=https://web.archive.org/web/20161128195011/https://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine/|archive-date=28 November 2016|url-status=dead}}</ref> While many patients get treated for life-threatening injuries, others utilize the emergency department (ED) for non-urgent reasons such as headaches or a cold. (defined as "visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome").<ref>{{Cite journal |last1=Uscher-Pines |first1=Lori |last2=Pines |first2=Jesse |last3=Kellermann |first3=Arthur |last4=Gillen |first4=Emily |last5=Mehrotra |first5=Ateev |date=2016-11-28 |title=Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature |journal=The American Journal of Managed Care |volume=19 |issue=1 |pages=47–59 |pmc=4156292 |pmid=23379744}}</ref> As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate various patient needs and volumes. Policies have improved to assist better ED staff (such as [[emergency medical technician]]s, [[paramedics]]). The emergency department, welfare programs, and healthcare clinics serve as a critical part of the healthcare safety net for uninsured patients who cannot afford medical treatment or adequately utilize their coverage.<ref name=":6">{{cite journal |doi=10.1111/j.1553-2712.2012.1446.x |pmid=22994373 |title=The Changing Landscape of America's Health Care System and the Value of Emergency Medicine |journal=Academic Emergency Medicine |volume=19 |issue=10 |pages=1204–11 |year=2012 |last1=Sasson |first1=Comilla |last2=Wiler |first2=Jennifer L. |last3=Haukoos |first3=Jason S. |last4=Sklar |first4=David |last5=Kellermann |first5=Arthur L. |last6=Beck |first6=Dennis |last7=Urbina |first7=Chris |last8=Heilpern |first8=Kathryn |last9=Magid |first9=David J. |doi-access=free}}</ref> 

In emergency departments in Australia, the government utilises an "Activity based funding and management", meaning that the amount of funding to emergency departments are allocated money based on the number of patients and the complexity of their cases or illnesses.<ref name="ww2.health.wa.gov.au">{{Cite web|url=https://ww2.health.wa.gov.au/Our-performance/Activity-based-funding-and-management|title=Activity based funding and management}}</ref> However, rural emergency departments of Australia are funded under the principle of providing the necessary equipment and staffing levels required to provide safe and adequate care, not necessarily on the number of patients.<ref name="ww2.health.wa.gov.au"/>

====Compensation====

In the United States, Emergency Physicians are compensated at a higher rate than some other specialities, ranking 10th out of 26 physician specialities in 2015, at an average salary of $306,000 annually.<ref>{{Cite web|url=http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=3|title=Medscape Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> They are compensated in the mid-range (averaging $13,000 annually) for non-patient activities, such as speaking engagements or acting as an expert witness; they also saw a 12% increase in salary from 2014 – 2015 (which was not out of line with many other physician specialities that year).<ref>{{Cite web|url=http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=4|title=Medscape Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> While emergency physicians work 8–12 hour shifts and do not tend to work on-call, the high level of stress and need for solid diagnostic and triage capabilities for the undifferentiated, acute patient contributes to arguments justifying higher salaries for these physicians.<ref>{{Cite web|url=http://www.medscape.com/viewarticle/750482|title=Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> Emergency care must be available every hour of every day and requires a doctor to be available on-site 24/7, unlike an outpatient clinic or other hospital departments with more limited hours and may only call a physician in when needed.<ref>{{cite book |last1=Shi |first1=L |last2=Singh |first2=D |title=Delivering health care in America: A systems approach |edition=6th |location=Burlington, Massachusetts |publisher=Jones & Bartlett Learning |year=2015 |page=264}}</ref> The necessity to have a physician on staff and all other diagnostic services available every hour of every day is thus a costly arrangement for hospitals.<ref>{{Cite web|url=http://newsroom.acep.org/fact_sheets?item=29928|title=Fact Sheets|website=American College of Emergency Physicians {{!}} News Room|access-date=2016-11-28|archive-date=5 May 2019|archive-url=https://web.archive.org/web/20190505041429/http://newsroom.acep.org/fact_sheets?item=29928|url-status=dead}}</ref>

====Payment systems====

American health payment systems are undergoing significant reform efforts,<ref>{{cite journal |pmid=15923928 |year=2005 |last1=Bebber |first1=R. J. |title=Reimbursement challenges for emergency physicians |journal=The Health Care Manager |volume=24 |issue=2 |pages=159–64 |last2=Liberman |first2=A |doi=10.1097/00126450-200504000-00009}}</ref> Which include compensating emergency physicians through "[[Pay for performance (healthcare)|pay for performance]]" incentives and penalty measures under commercial and public health programs, including Medicare and Medicaid. This payment reform aims to improve the quality of care and control costs, despite the differing opinions on the existing evidence to show that this payment approach is effective in emergency medicine.<ref name="ReferenceA">{{cite journal |doi=10.1056/NEJMe1212133 |pmid=23134388 |title=Will Pay for Performance Improve Quality of Care? The Answer is in the Details |journal=New England Journal of Medicine |volume=367 |issue=19 |pages=1852–3 |year=2012 |last1=Epstein |first1=Arnold M.}}</ref> Initially, these incentives would only target primary care providers (PCPs), but some would argue that emergency medicine is primary care, as no one refers patients to the ED.<ref>{{Cite web|url=https://www.aamc.org/download/100598/data/|title=Recent Studies and Reports on Physician Shortages in the US: Emergency Medicine (2009) – "Emergency Care System Remains in Serious Condition"|date=October 2012|pages=13|archive-url=https://web.archive.org/web/20161021204254/https://www.aamc.org/download/100598/data/|archive-date=21 October 2016|url-status=dead}}</ref><ref name="ReferenceA"/> In one such program, two specific conditions listed were directly tied to patients frequently seen by emergency medical providers: acute myocardial infarction and pneumonia.<ref>{{cite journal |doi=10.1016/j.annemergmed.2006.06.032 |pmid=16979264 |title=Pay for Performance in Emergency Medicine |journal=Annals of Emergency Medicine |volume=49 |issue=6 |pages=756–61 |year=2007 |last1=Sikka |first1=Rishi}}</ref> (See: [[Hospital Quality Incentive Demonstration]].)

There are some challenges with implementing these quality-based incentives in emergency medicine in that patients are often not given a definitive diagnosis in the ED, making it challenging to allocate payments through [https://www.aapc.com/medical-coding/medical-coding.aspx coding].  Additionally, adjustments based on patient risk-level and multiple co-morbidities for complex patients further complicate attribution of positive or negative health outcomes. It is not easy to assess whether much of the costs directly result from the emergent condition treated in acutely care settings.<ref>{{Cite web|url=https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|title=Emergency Medicine and Payment Reform // ACEP|website=acep.org|access-date=2016-11-28|archive-url=https://web.archive.org/web/20161129021328/https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|archive-date=29 November 2016|url-status=dead}}</ref> It is also difficult to quantify the savings due to preventive care during emergency treatment (i.e. workup, stabilizing treatments, coordination of care and discharge, rather than a hospital admission). Thus, ED providers tend to support a modified fee-for-service model over other payment systems.<ref>{{Cite web|url=https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|title=Ibid|website=acep.org|access-date=2016-11-28|archive-url=https://web.archive.org/web/20161129021328/https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|archive-date=29 November 2016|url-status=dead}}</ref>

==== Overutilization ====

Some patients without health insurance utilize EDs as their primary form of medical care, as their financial status limits their access to consistent care. Because these patients cannot utilize insurance or primary care systems, emergency medical providers often increased volumes of lower acuity patients and risk of financial loss, especially since many patients cannot pay for their care (see below). ED overuse produces $38 billion in spending each year (i.e. care delivery and coordination failures, over-treatment, administrative complexity, pricing failures, and fraud),<ref name=":7">{{Cite web|url=http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf|title=A Matter of Urgency: Reducing Emergency Department Overuse|date=March 2010|website=NEHI Research Brief|publisher=New England Healthcare Institute|access-date=16 November 2016|archive-date=23 November 2016|archive-url=https://web.archive.org/web/20161123064444/http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf|url-status=dead}}</ref><ref>{{Cite web|url=http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82|title=Reducing Waste in Health Care|website=Health Affairs – Health Policy Briefs|access-date=2016-11-28}}</ref> Moreover, it unnecessarily drains departmental resources, reducing the quality of care across all patients. While overuse is not limited to the uninsured, the uninsured constitute a growing proportion of non-urgent ED visits.<ref>{{cite journal |doi=10.1016/j.annemergmed.2008.01.327 |pmid=18407374 |title=Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States? |journal=Annals of Emergency Medicine |volume=52 |issue=2 |pages=108–15 |year=2008 |last1=Weber |first1=Ellen J. |last2=Showstack |first2=Jonathan A. |last3=Hunt |first3=Kelly A. |last4=Colby |first4=David C. |last5=Grimes |first5=Barbara |last6=Bacchetti |first6=Peter |last7=Callaham |first7=Michael L.}}</ref> Insurance coverage can help mitigate overutilization by improving access to alternative forms of care and lowering the need for emergency visits.<ref name=":6" /><ref>{{cite journal |doi=10.1007/s10900-016-0293-4 |pmid=27837359 |title=Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion |journal=Journal of Community Health |volume=42 |issue=3 |pages=591–597 |year=2016 |last1=Sharma |first1=Aabha I. |last2=Dresden |first2=Scott M. |last3=Powell |first3=Emilie S. |last4=Kang |first4=Raymond |last5=Feinglass |first5=Joe |s2cid=25647447}}</ref>

A common misconception identifies frequent ED visitors as a significant factor in excess spending. However, frequent ED users make up a small portion of those contributing to overutilization and are often insured.<ref>{{Cite web |url=https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf |title=Characteristics of Frequent Emergency Department Users |date=October 2007 |publisher=The Henry J. Kaiser Family Foundation |access-date=16 November 2016 |archive-url=https://web.archive.org/web/20161128200549/https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf |archive-date=28 November 2016 |url-status=dead}}</ref>

=== Uncompensated care ===

Injury and illness are often unforeseen, and patients of lower socioeconomic status are especially susceptible to being suddenly burdened with the cost of a necessary ED visit. For example, in the event that a patient is unable to pay for medical care received, the hospital, under the Emergency Medical Treatment and Active Labor Act ([[Emergency Medical Treatment and Active Labor Act|EMTALA]]), is obligated to treat emergency conditions regardless of a patient's ability to pay and therefore faces an economic loss for this uncompensated care.<ref>{{Cite web|url=https://www.healthcare.gov/glossary/uncompensated-care/|title=Uncompensated Care – HealthCare.gov Glossary|website=HealthCare.gov|access-date=2016-11-21}}</ref> Estimates suggest that over half (approximately 55%) of all quantifiable emergency care is uncompensated<ref>{{Cite web|url=https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/Downloads/cms1204fc_1.pdf|title=Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2003 and Inclusion of Registered Nurses in the Personnel Provision of the Critical Access Hospital Emergency Services Requirement for Frontier Areas and Remote Locations|date=31 December 2002|website=Federal Register|publisher=Department of Health and Human Services, Centers for Medicare & Medicaid Services|access-date=16 November 2016}}</ref><ref>{{Cite journal |pmid=16292008 |year=2005 |last1=Langland-Orban |first1=B |title=Uncompensated care provided by emergency physicians in Florida emergency departments |journal=Health Care Management Review |volume=30 |issue=4 |pages=315–21 |last2=Pracht |first2=E |last3=Salyani |first3=S |doi=10.1097/00004010-200510000-00005|citeseerx=10.1.1.517.2055 |s2cid=8406}}</ref> and inadequate reimbursement has led to the closure of many EDs.<ref>{{Cite web|url=http://newsroom.acep.org/fact_sheets?item=29928|title=Costs of Emergency Care Fact Sheet|publisher=American College of Emergency Physicians|access-date=16 November 2016|archive-date=5 May 2019|archive-url=https://web.archive.org/web/20190505041429/http://newsroom.acep.org/fact_sheets?item=29928|url-status=dead}}</ref> Policy changes (such as the [[Patient Protection and Affordable Care Act|Affordable Care Act]]) are expected to decrease the number of uninsured people and thereby reduce uncompensated care.<ref>{{Cite web|url=https://www.hhs.gov/about/news/2014/09/24/new-report-projects-5-7-billion-drop-in-hospitals-uncompensated-care-costs-because-of-the-affordable-care-act.html|title=New report projects a $5.7 billion drop in hospitals' uncompensated care costs because of the Affordable Care Act|date=24 September 2014|website=News|publisher=U.S. Department of Health & Human Services|access-date=16 November 2016}}</ref>

In addition to decreasing the uninsured rate, ED overutilization might reduce by improving patient access to primary care and increasing patient flow to alternative care centres for non-life-threatening injuries. Financial disincentives, patient education, and improved management for patients with chronic diseases can also reduce overutilization and help manage costs of care.<ref name=":7" /> Moreover, physician knowledge of prices for treatment and analyses, discussions on costs with their patients, and a changing culture away from defensive medicine can improve cost-effective use.<ref>{{cite journal |doi=10.1097/MEJ.0b013e32833651f0 |pmid=20093935 |title=Cutting costs: The impact of price lists on the cost development at the emergency department |journal=European Journal of Emergency Medicine |volume=17 |issue=6 |pages=337–9 |year=2010 |last1=Schilling |first1=Ulf Martin |s2cid=28621380}} Also: {{cite journal|pmc=3313286 | volume=17 | issue=Suppl 2 | journal=Scand J Trauma Resusc Emerg Med | title=Cutting costs – the impact of price-lists on the cost development in the emergency department | year= 2009| doi=10.1186/1757-7241-17-s2-p2| last1=Schilling | first1=Ulf | pages=337–9 | pmid=20093935 | doi-access=free }}</ref><ref>{{cite journal |doi=10.1016/j.ajem.2013.07.019 |pmid=23993868 |title=A 'Top Five' list for emergency medicine: A policy and research agenda for stewardship to improve the value of emergency care |journal=The American Journal of Emergency Medicine |volume=31 |issue=10 |pages=1520–4 |year=2013 |last1=Venkatesh |first1=Arjun K. |last2=Schuur |first2=Jeremiah D.}}</ref> A transition towards more value-based care in the ED is an avenue by which providers can contain costs.

====EMTALA====

Doctors that work in the EDs of hospitals receiving Medicare funding are subject to the provisions of [[EMTALA]].<ref name=":2">{{Cite web|url=https://www.law.cornell.edu/uscode/text/42/1395dd|title=42 U.S. Code § 1395dd – Examination and treatment for emergency medical conditions and women in labor|website=LII / Legal Information Institute|access-date=2016-11-19}}</ref> The US Congress enacted EMTALA in 1986 to curtail "patient dumping", a practice whereby patients were refused medical care for economic or other non-medical reasons.<ref name=":3">{{cite journal |pmid=15002183 |year=2004 |last1=Lee |first1=T. M. |title=An EMTALA primer: The impact of changes in the emergency medicine landscape on EMTALA compliance and enforcement |journal=Annals of Health Law |volume=13 |issue=1 |pages=145–78, table of contents}}</ref> Since its enactment, ED visits have substantially increased, with one study showing a rise in visits of 26% (which is more than double the increase in population over the same period).<ref name=":4">{{Cite journal |last=Dollinger |first=Tristan |year=2015 |title=America's Unraveling Safety Net: EMTALA's Effect on Emergency Departments, Problems and Solutions |url=http://scholarship.law.marquette.edu/mulr/vol98/iss4/9 |journal=Marquette Law Review |volume=98 |pages=1759}}</ref> While more individuals are receiving care, a lack of funding and ED overcrowding may be affecting quality.<ref name=":4" /> To comply with the provisions of EMTALA, hospitals, through their ED physicians, must provide medical screening and stabilize the emergency medical conditions of anyone that presents themselves at a hospital ED with patient capacity.<ref name=":3" /> EMTALA holds both the hospital and the responsible ED physician liable for civil penalties of up to $50,000 if there is no help for those in need.<ref name=":2" /> While both the [[Office of Inspector General, U.S. Department of Health and Human Services]] (OIG) and private citizens can bring an action under EMTALA, courts have uniformly held that ED physicians can only be held liable if the case is prosecuted by OIG (whereas hospitals are subject to penalties regardless of who brings the suit).<ref>{{Cite news|url=http://law.justia.com/cases/federal/district-courts/FSupp/786/538/1380004/|title=Jones v. Wake County Hosp. System, Inc., 786 F. Supp. 538 (E.D.N.C. 1991)|newspaper=Justia Law|access-date=2016-11-19}}</ref><ref>{{Cite news|url=http://law.justia.com/cases/federal/district-courts/FSupp/756/1476/2291188/|title=Delaney v. Cade, 756 F. Supp. 1476 (D. Kan. 1991)|newspaper=Justia Law|access-date=2016-11-19}}</ref><ref>{{Cite journal|last=Circuit.|first=United States Court of Appeals, Fourth|date=1992-10-07|title=977 F2d 872 Baber v. Hospital Corporation of America Hca B|url=http://openjurist.org/977/f2d/872/baber-v-hospital-corporation-of-america-hca-b|volume=F2d|issue=977|page=872}}</ref> Additionally, the Centres for Medicare and Medicaid Services (CMS) can discontinue provider status under Medicare for physicians that do not comply with EMTALA.<ref name=":3" /> Liability also extends to on-call physicians that fail to respond to an ED request to come to the hospital to provide service.<ref name=":2" /><ref>{{Cite web|url=https://www.acep.org/clinical---practice-management/cms-question-and-answer-program-memorandum-on-emtala-on-call-responsibilities/|title=CMS Question and Answer Program Memorandum on EMTALA On-Call Responsibilities // ACEP|website=acep.org|access-date=2016-11-19|archive-url=https://web.archive.org/web/20161128195134/https://www.acep.org/clinical---practice-management/cms-question-and-answer-program-memorandum-on-emtala-on-call-responsibilities/|archive-date=28 November 2016|url-status=dead}}</ref> While the goals of EMTALA are laudable, commentators have noted that it appears to have created a substantial unfunded burden on the resources of hospitals and emergency physicians.<ref name=":4" /><ref>{{cite journal |pmid=10179281 |year=1998 |last1=Hyman |first1=D. A. |title=Patient dumping and EMTALA: Past imperfect/future shock |journal=Health Matrix |volume=8 |issue=1 |pages=29–56}}</ref> As a result of financial difficulty, between the period of 1991–2011, 12.6% of EDs in the US closed.<ref name=":4" />

=== Care delivery in different ED settings ===

==== Rural ====
Despite the practice emerging over the past few decades, the delivery of emergency medicine has significantly increased and evolved across diverse settings related to cost, provider availability and overall usage. Before the Affordable Care Act (ACA), low-acuity emergency medicine visits were leveraged primarily by "uninsured or underinsured patients, women, children, and minorities, all of whom frequently face barriers to accessing primary care".<ref>{{cite journal |doi=10.1097/01.mlr.0000045021.70297.9f |pmid=12555048 |title=Emergency Department Visits for Ambulatory Care Sensitive Conditions |journal=Medical Care |volume=41 |issue=2 |pages=198–207 |year=2003 |last1=Oster |first1=Ady |last2=Bindman |first2=Andrew B. |s2cid=24666109}}</ref> While this still exists today, as mentioned above, it is critical to consider the location in which care is delivered to understand the population and system challenges related to overutilization and high cost. In rural communities where provider and ambulatory facility shortages exist, a primary care physician (PCP) in the ED with general knowledge is likely to be the only source of health care for a population, as specialists and other health resources are generally unavailable due to lack of funding and desire to serve in these areas.<ref>{{cite book |chapter=Improving efficiency and preserving access to emergency care in rural areas |publisher=MEDPAC |chapter-url=http://www.medpac.gov/docs/default-source/reports/chapter-7-improving-efficiency-and-preserving-access-to-emergency-care-in-rural-areas-june-2016-repo.pdf |title=Report to the Congress: Medicare and the Health Care Delivery System |date=June 2016 |access-date=28 November 2016 |archive-date=3 February 2017 |archive-url=https://web.archive.org/web/20170203083954/http://www.medpac.gov/docs/default-source/reports/chapter-7-improving-efficiency-and-preserving-access-to-emergency-care-in-rural-areas-june-2016-repo.pdf |url-status=dead}}</ref> As a result, the incidence of complex co-morbidities not managed by the appropriate provider results in worse health outcomes and eventually costlier care that extends beyond rural communities. Though typically quite separated, PCPs in rural areas must partner with larger health systems to comprehensively address the complex needs of their community, improve population health, and implement strategies such as telemedicine to improve health outcomes and reduce ED utilization for preventable illnesses.<ref>{{cite journal |doi=10.1111/j.1748-0361.2008.00156.x |pmid=18397454 |title=Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments |journal=The Journal of Rural Health |volume=24 |issue=2 |pages=183–8 |year=2008 |last1=Peterson |first1=Lars E. |last2=Dodoo |first2=Martey |last3=Bennett |first3=Kevin J. |last4=Bazemore |first4=Andrew |last5=Phillips |first5=Robert L.}}</ref><ref>{{cite press release |title=$22.1 Million to Improve Access to Health Care in Rural Areas |publisher=Health Resources and Services Administration |date=26 September 2014 |url=https://www.hrsa.gov/about/news/pressreleases/140926ruralhealth.html |access-date=29 January 2017}}</ref> (See: [[Rural health]].)

Rural care has benefitted in the post-pandemic (2020) era by the rapid expansion of telemedicine programs, including those that assist with Emergency Medical care. This has enhanced the ability of non-Emergency Medicine boarded physicians, physician assistants and nurse practitioners to provide a higher level of care by partnering with Emergency Physicians at larger centers, via telehealth.<ref>Expanding access to emergency care in rural hospitals. Department of Health and Human Services. https://telehealth.hhs.gov/community-stories/expanding-access-emergency-care-rural-hospitals#:~:text=Rural%20hospitals%20can%20use%20telehealth,assist%20staff%20in%20rural%20hospitals. Accessed 2024-12-28.</ref>

==== Urban ====
Alternatively, emergency medicine in urban areas consists of diverse provider groups, including [[physician]]s, [[physician assistant]]s, nurse practitioners and registered nurses who coordinate with specialists in both inpatient and outpatient facilities to address patients' needs, more specifically in the ED. For all systems, regardless of funding source, EMTALA mandates EDs to conduct a medical examination for anyone that presents at the department, irrespective of paying ability.<ref>EMTALA. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/ . Accessed 2016-11-15.
</ref> Non-profit hospitals and health systems – as required by the ACA – must provide a certain threshold of charity care "by actively ensuring that those who qualify for financial assistance get it, by charging reasonable rates to uninsured patients and by avoiding extraordinary collection practices."<ref>Kutscher B. Hospitals fall short on ACA charity-care rules. Modern Healthcare. http://www.modernhealthcare.com/article/20151028/news/151029886 . Published 28 October 2015. Accessed 2016-11-16.</ref> While there are limitations, this mandate provides support to many in need. That said, despite policy efforts and increased funding and federal reimbursement in urban areas, the triple aim (of improving patient experience, enhancing population health, and reducing the per-capita cost of care) remains a challenge without providers' and payers' collaboration to increase access to preventive care and decrease in ED usage. As a result, many experts support the notion that emergency medical services should only serve immediate risks in urban and rural areas.

==== Patient–provider relationships ====
As stated above, EMTALA includes provisions that protect patients from being turned away or transferred before adequate stabilisation. Upon making contact with a patient, EMS providers are responsible for diagnosing and stabilising a patient's condition without regard for the ability to pay. In the pre-hospital setting, providers must exercise appropriate judgement in choosing a suitable hospital for transport. Hospitals can only turn away incoming ambulances if they are on diversion and incapable of providing adequate care. However, once a patient has arrived on hospital property, care must be provided. At the hospital, a triage nurse first contacts the patient, who determines the appropriate level of care needed.

According to ''Mead v. Legacy Health System'',<ref>{{Citation|title=Mead v. Legacy Health System|date=26 July 2012|url=https://scholar.google.com/scholar_case?case=3832184832260263822&q=Mead+v.+Legacy+Health+System,+283+P.3d+904,+352+Or.+267+(2012).&hl=en&as_sdt=2006|volume=283|pages=904|access-date=2016-11-21}}</ref> a patient-physician relationship is established when "the physician takes an affirmative action with regard to the care of the patient". Initiating such a relationship forms a legal contract in which the physician must continue to provide treatment or adequately terminate the relationship.<ref>{{cite journal |doi=10.1001/virtualmentor.2012.14.5.hlaw1-1205 |pmid=23351207 |title=When is a Patient-Physician Relationship Established? |journal=Virtual Mentor |volume=14 |issue=5 |pages=403–6 |year=2012 |last1=Blake |first1=V}}</ref> This legal responsibility can extend to physician consultations and on-call physicians even without direct patient contact. In emergency medicine, termination of the patient–provider relationship prior to stabilization or without handoff to another qualified provider is considered abandonment. In order to initiate an outside transfer, a physician must verify that the next hospital can provide a similar or higher level of care. Hospitals and physicians must also ensure that the patient's condition will not be further aggravated by the transfer process.

The setting of emergency medicine presents a challenge for delivering high quality, patient-centered care. Clear, effective communication can be particularly difficult due to noise, frequent interruptions, and high patient turnover.<ref name=":5">{{cite journal |pmid=15332069 |year=2004 |last1=Rhodes |first1=K. V. |title=Resuscitating the physician-patient relationship: Emergency department communication in an academic medical center |journal=Annals of Emergency Medicine |volume=44 |issue=3 |pages=262–7 |last2=Vieth |first2=T |last3=He |first3=T |last4=Miller |first4=A |last5=Howes |first5=D. S. |last6=Bailey |first6=O |last7=Walter |first7=J |last8=Frankel |first8=R |last9=Levinson |first9=W |doi= 10.1016/j.annemergmed.2004.02.035|url=https://repository.upenn.edu/spp_papers/108}}</ref> The Society for Academic Emergency Medicine has identified five essential tasks for patient-physician communication: establishing rapport, gathering information, giving information, providing comfort, and collaboration.<ref name=":5" /> The miscommunication of patient information is a crucial source of medical error; minimising shortcoming in communication remains a topic of current and future research.<ref>{{cite journal |doi=10.4300/JGME-D-11-00256.1 |pmid=24294436 |pmc=3546588 |title=Patient Communication During Handovers Between Emergency Medicine and Internal Medicine Residents |journal=Journal of Graduate Medical Education |volume=4 |issue=4 |pages=533–7 |year=2012 |last1=Fischer |first1=Miriam |last2=Hemphill |first2=Robin R. |last3=Rimler |first3=Eva |last4=Marshall |first4=Stephanie |last5=Brownfield |first5=Erica |last6=Shayne |first6=Philip |last7=Di Francesco |first7=Lorenzo |last8=Santen |first8=Sally A.}}</ref>

====Medical error====
Many circumstances, including the regular transfer of patients in emergency treatment and crowded, noisy and chaotic ED environments, make emergency medicine particularly susceptible to [[medical error]] and near misses.<ref name=":0">{{cite book |doi=10.1002/9781118292150 |title=Ethical Problems in Emergency Medicine |year=2012 |isbn=9781118292150 |editor1-last=Jesus |editor1-first=John |editor2-last=Grossman |editor2-first=Shamai A |editor3-last=Derse |editor3-first=Arthur R |editor4-last=Adams |editor4-first=James G |editor5-last=Wolfe |editor5-first=Richard |editor6-last=Rosen |editor6-first=Peter}}</ref><ref name=":1">{{cite journal |doi=10.1016/s0196-0644(03)00398-6 |pmid=12944883 |title=Errors in a busy emergency department |journal=Annals of Emergency Medicine |volume=42 |issue=3 |pages=324–33 |year=2003 |last1=Fordyce |first1=James |last2=Blank |first2=Fidela S.J. |last3=Pekow |first3=Penelope |last4=Smithline |first4=Howard A. |last5=Ritter |first5=George |last6=Gehlbach |first6=Stephen |last7=Benjamin |first7=Evan |last8=Henneman |first8=Philip L.}}</ref> One study identified an error rate of 18 per 100 registered patients in one particular academic ED.<ref name=":1" /> Another study found that where a lack of teamwork (i.e. poor communication, lack of team structure, lack of cross-monitoring) was implicated in a particular incident of ED medical error, "an average of 8.8 teamwork failures occurred per case [and] more than half of the deaths and permanent disabilities that occurred were judged avoidable."<ref>{{cite journal |doi=10.1016/s0196-0644(99)70134-4 |pmid=10459096 |title=The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department |journal=Annals of Emergency Medicine |volume=34 |issue=3 |pages=373–83 |year=1999 |last1=Risser |first1=Daniel T |last2=Rice |first2=Matthew M |last3=Salisbury |first3=Mary L |last4=Simon |first4=Robert |last5=Jay |first5=Gregory D |last6=Berns |first6=Scott D}}</ref> Particular cultural (i.e. "a focus on the errors of others and a 'blame-and-shame' culture") and structural (i.e. lack of standardisation and equipment incompatibilities) aspects of emergency medicine often result in a lack of disclosure of medical error and near misses to patients and other caregivers.<ref name=":0" /><ref>{{cite journal |doi=10.1111/j.1553-2712.2008.00147.x |pmid=19086213 |title=Emergency Medical Services Provider Perceptions of the Nature of Adverse Events and Near-misses in Out-of-hospital Care: An Ethnographic View |journal=Academic Emergency Medicine |volume=15 |issue=7 |pages=633–40 |year=2008 |last1=Fairbanks |first1=Rollin J. |last2=Crittenden |first2=Crista N. |last3=o'Gara |first3=Kevin G. |last4=Wilson |first4=Matthew A. |last5=Pennington |first5=Elliot C. |last6=Chin |first6=Nancy P. |last7=Shah |first7=Manish N. |doi-access=free}}</ref> While concerns about malpractice liability are one reason why disclosure of medical errors is not made, some have noted that disclosing the error and providing an apology can mitigate malpractice risk.<ref>{{Cite web|url=http://news.health.com/2010/08/17/when-doctors-admit-mistakes-fewer-malpractice-suits-result-study-says/|title=When Doctors Admit Mistakes, Fewer Malpractice Suits Result, Study Says|date=2010-08-17|website=Health News / Tips & Trends / Celebrity Health|access-date=2016-11-19|archive-url=https://web.archive.org/web/20161128195708/http://news.health.com/2010/08/17/when-doctors-admit-mistakes-fewer-malpractice-suits-result-study-says/|archive-date=28 November 2016|url-status=dead}}</ref> Ethicists uniformly agree that the disclosure of a medical error that causes harm is a care provider's duty.<ref name=":0" /> The critical components of the disclosure include "honesty, explanation, empathy, apology, and the chance to lessen the chance of future errors" (represented by the mnemonic HEEAL).<ref name=":0" /><ref>{{cite journal |doi=10.1001/jama.289.8.1001 |pmid=12597752 |title=Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors |journal=JAMA |volume=289 |issue=8 |pages=1001–7 |year=2003 |last1=Gallagher |first1=Thomas H. |last2=Waterman |first2=A. D. |last3=Ebers |first3=A. G. |last4=Fraser |first4=V. J. |last5=Levinson |first5=W |doi-access=free}}</ref> The nature of emergency medicine is such that error will likely always be a substantial risk of emergency care. However, maintaining public trust through open communication regarding a harmful error can help patients and physicians constructively address problems when they occur.<ref name=":0" />