Fee for "non-emergency" visits to the ED

[blackavar]

Texas Emergency Rooms and Elsewhere Levy Fees for Some Care

Came across this article on yahoo just now; talking about after an initial work up and "decision" that a patient is "not sick enough to merit ED treatment" the patient can decide to leave then or continue ED treatment for an additional upfront fee. The article brings up some pros and cons for the system.

I won't lie, initially I was pretty taken aback by this idea...at times physicians struggle with identifying how sick a patient is, now we're asking our patients to guess before they even come to the ED? Also, what if they're referred to the ED from their PCP...does the PCP they pay the fee or does it still rest with the patient?

Trying to keep an open mind about the whole thing, I was somewhat curious if anyone out there works in a system that employs this and what their thoughts were...

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[Apollyon]

When I was working in SC 4 years ago, we were doing that, according to a schedule we had generated for serial trivial users of the department. They would get a "screening exam" (vitals reviewed, gross neuro, lungs, heart), and then be told that a financial counselor would be in to see them. A few walked right out, most feigned (maybe) ignorance, and a few actually paid.

 

[DeadCactus]

So do you charge patients based on presentation or final diagnosis? The later seems ridiculous and the former just seems like more of a reason for patients to lie about symptoms...

 

[Apollyon]

So do you charge patients based on presentation or final diagnosis? The later seems ridiculous and the former just seems like more of a reason for patients to lie about symptoms...

Ours was presenting complaint (including dental pain and back pain), but was triage level 5's (lowest). It also dealt with how many visits over a period of time. If someone met all these criteria, we could do it on our own initiative.

 

[docB]

We do it. We see them and if it's non-emergent they go to admitting and are told they can provide proof of insurance or pay a deposit. Note that this is a hospital issue. We don't bill them if they're non-emergent and we don't get any of the deposit if they decide to pay it.

I think it's a reasonable system for educating people what they shouldn't come to the ER for but for many it's an access issue. They don't have anywhere else to go.

 

[Arcan57]

We do it at our hospital. It's for patients that don't have an emergency condition and essentially people you wouldn't be working up anyway. The way I phrased it is that you don't have an emergency condition in the billing offices can talk to you and you won't have to pay for the visit. Because Lupe she will want to pay the deposit to get's prescription for their nonemergent condition but in general they are happy just to get seen. Our hospital pays us in between a level I and II visit for each screen out.

 

[Hamhock]

We do it. We see them and if it's non-emergent they go to admitting and are told they can provide proof of insurance or pay a deposit. Note that this is a hospital issue. We don't bill them if they're non-emergent and we don't get any of the deposit if they decide to pay it.

I think it's a reasonable system for educating people what they shouldn't come to the ER for but for many it's an access issue. They don't have anywhere else to go.

This seems like a good start...now if the hospital could just ask for a bit more of a "deposit" and have a primary care clinic next door to the admitting/billing department they were sent to. This would "help the community" and keep this out of the ED.

I never understood why public hospitals don't do this with their "urgent care" centers. Quick medical screening exam and then send them to the line at the walk-in primary care clinic next door.

HH

 

[UnderwaterDoc]

Why would we want to keep "non-emergent visits" from coming to the ED? Job security people.

 

[TrumpetDoc]

I'm all for it. Not concerned about loosing too many patients with something like this.


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[mlw47]

I'm not a fan of low acuity patients either, but being really aggressive about that kind of stuff could get you in trouble for some kind of financial intimidation. Granted, that's what you want: people to be cost conscious. But you also don't want people to be afraid to come to the ER due to cost when they're having an actual emergency. Are there more specific laws besides EMTLA or case law that prohibit or permit this practice?

 

[Apollyon]

But you also don't want people to be afraid to come to the ER due to cost when they're having an actual emergency.

But that is part of the central tenet - it is multiple visit users, with a demonstrated history of minor complaints, with the same complaint. They get seen by a doctor. That's the point - the screening exam. It is possible for the screen to miss an actual emergency, but there would have to be an array of confounding factors to get a bad outcome. I mean, if the person appears NAD, their presenting complaint is dental pain, they have been seen 5 times in the past 5 months for dental pain, and their vitals are stone cold normal, sure, an emergency could be happening, but it would sound like it would not pass the reasonable man test (that an equivalent reasonable man would find the problem).

 

[mlw47]

I totally agree that there's a super small subset of patients that this could work for. But god forbid you ever miss a single sick person. And god forbid if the press or community hears about this. It could totally be misconstrued the wrong way and would be an absolute PR nightmare.

My hospital is blessed by the absolute best ER case managers. A much better disposition would be be to get those chronic users plugged into the right system, get them enrolled in an entitlement program or the state health insurance (if they're uninsured), and turf them elsewhere!

 

[Arcan57]

I'm not a fan of low acuity patients either, but being really aggressive about that kind of stuff could get you in trouble for some kind of financial intimidation. Granted, that's what you want: people to be cost conscious. But you also don't want people to be afraid to come to the ER due to cost when they're having an actual emergency. Are there more specific laws besides EMTLA or case law that prohibit or permit this practice?

So the whole point of screening out non-emergent patients is to be compliant with EMTALA. They receive a medical screening exam by a physician or midlevel, which consists of the same H&P they would get normally. EMTALA mandates that the patient must be stabilized if they have an emergency medical condition. If the patient does not have an emergency condition, then they are given the option of being referred to a clinic or paying their co-pay (if they have insurance) or a deposit (if they don't) to be treated in the ED.

This is different then case management coming up with a care plan for chronic abusers of the ED, as many of our screen-outs are first time visitors. The average screen-out is a pediatric URI, although dental pain and chronic low back pain are common also.

The typical screen-out is not an acrimonious process. The alternative to being screened out for most of them is to pay an expensive bill to get the same instructions I just gave them, but printed out. The amount of documentation doesn't change (you still need to cover yourself medicolegally), and these are patients that by definition you wouldn't be working up anyway.

 

[Birdstrike]

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[docB]

To Arcan and Birdstrike. It sounds like my system and Arcan's work the same way. In my system we get nothing from the hospital.

Birdstrike touches on my main issue with the system. The biggest con the way this seems to be implemented in most places is that the hospital saves money while ALL of the liability is transferred to the doc (and/or midlevel who is usually employed by the physician group). We are forced to do under threat of losing the contract.

I do think there is a place for this in EM. There has to be some sort of soft stop and reality check for people. It serves an educational function. But it really needs to be coupled with limited liability, social work/case management intervention and actual timely primary care follow up.

 

[docB]

BTW here's a thread from 2005 that I started when this was just something coming down the pike. I'm obviously not as scared of it now as I once was having lived through it but it's interesting to see how these things play out.

http://forums.studentdoctor.net/showthread.php?t=167548

 

[bartleby]

DocB and birdstrike are right...this increases liability for docs without improving throughout or care in the ED. These problems are societal and legislative EMTALA issues. The solution is to keep them out of the ED in the first place not to secondarily ding them after the provider has already burnt X minutes screening them. EDs are the canaries in the deelp, dark coal mine of American healthcare. The fact that EDs have resorted to doing stuff like this is a sign of how distressed they have become.

 

[GeneralVeers]

This is why I think the MSE should compose two major reforms:

1. All hospitals and physicians who meet the basic requirements of an MSE and document appropriately are absolved of any liability from a missed emergency.

2. Nurses perform the MSE as part of triage.

Without the above two things, any system for screening out non-emergencies can't work.

There was an interesting article about ED costs in the ACEP newspaper yesterday. Emergency department visits cost 2% of national healthcare spending. That's useful, because even if we could screen out 10% of people as non-emergent, we'd be saving 0.2% of all healthcare costs. Hardly worth it for the liability issues it represents.

The real savings are in end-of life care. 80% of Medicare money is spent in futile or near-futile care at end of life. We could make Medicare solvent by just stopping the nonsense and saying "no" to the patients who seek this care.

 

[cofcemt]

The real savings are in end-of life care. 80% of Medicare money is spent in futile or near-futile care at end of life. We could make Medicare solvent by just stopping the nonsense and saying "no" to the patients who seek this care.

This is the single most important point if we don't want Medicare to go down in flames.

 

[docB]

The real savings are in end-of life care. 80% of Medicare money is spent in futile or near-futile care at end of life. We could make Medicare solvent by just stopping the nonsense and saying "no" to the patients who seek this care.

Minor point but it's the families who demand this care. Usually not the patients. To say "no" will require more liability protection as well as protection from "dissatisfied" parties. You can not win the HCAHPs game and deny care.

 

[Apollyon]

Minor point but it's the families who demand this care. Usually not the patients. To say "no" will require more liability protection as well as protection from "dissatisfied" parties. You can win the HCAHPs game and deny care.

Can or cannot?

 

[docB]

Can or cannot?

Dammit!

Ok. Fixed it. Thanks. That's what happens when I type when I'm that tired.