ER Copays

[docB]

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We all know that the ER is abused by a variety of people. The idea of using copays to try to reduce this abuse is often put forward.

Let me start the discussion by saying that philosophically I support the idea of copays. I think that it is important for patients to have some "skin in the game.*" But in reality I don't think they will work. Here's why:

We can't and shouldn't deny people really emergent care because of inability to pay. Consequently any system we would use would have to try to distinguish between the emergent and the non-emergent. There will be errors and inequities in any system we create. That will cause liability and bad press which few of us and none of our administrators are willing to risk.

It is impossible to be a steward of anything and achieve patient satisfaction. Copays will really irk those required to pay them.

If we were able to apply copays to Medicaid patients (which would be necessary to really make this work) we would see people not getting care. These people by definition are not good with money. We all know that they have no money for meds, dentists, primary care, etc. but they all seem to be able to afford smokes, cell phones, fake nails, extensive tattooing and so on. They will not pay ER copays and will complain to everyone, including politicians and reporters, that they have been denied care and X,Y or Z bad outcome has resulted.

*Some would argue that a potential patient trying to get care from an ER has the most "skin in the game" of anyone. We all know that a large number of patients come to the ER to avoid the inconvenience of making a PMD appointment and/or paying for it. If you're having an MI you do indeed have skin in the game. If you have a cold and came in because we are free and 24/7 then your attitude could benefit from a copay.

 

[deleted109597]

To make it actually work, there would have to be a lot more bureaucracy added. You would need some CMS representative to determine emergent vs non-emergent (see the state of Washington for rules), and then apply copay to the "non-emergent". Of course, you would see more diagnosis changing from URI to "bronchitis" or the like so that you get paid more as well. I think nothing would come of up front payment. What Medicare needs to do is start making them pay for it at home after the visit, then suddenly they would stop coming if they knew their welfare check was going to get docked for "abuse".

 

[EM2BE]

I have rotated at different hospitals that have a person that will walk around when patients are soon to be discharged and will ask for partial / full payment for the visit. I have heard them saying "Can you just pay even 1 dollar?" I think that was something that could be implemented (paying after being in the ED and just prior to DC). It was amazing to hear people scrambling through their bags and counting out how much cash they had. I remember a few that had less than $10 and still needed to pay for the bus/cab to take them home. They would say they couldn't even afford 50 cents.

 

[NinerNiner999]

I wonder about two other aspects about this. Once a patient is deemed "non-emergent" but seen in the ED, can the physician still bill them as "emergent"? Will the cronies at CMS reject ER level of service? Will this open up potential for Medicare Fraud?

Press Gainey will be even more skewed than it already is when these patients who had to pay cash get their surveys? Will they be excluded?

 

[Flopotomist]

Are you trying to raise revenue for the ED, or encourage more appropriate use of the ED by low income pts? A copay might accomplish the first goal (minimally), but will do little to address the second goal as there will always be a work-around. For example, pts will learn to say "chest pain" in order to get around the lady at the cash register, and then demand evaluation for what they really want, and it will likely be easier to just give in and give it then send them back out to pay their co-pay.

What might help with the first though would be things like a "privelige pay" or some such wherein you pay $20 to be seen faster (within your triage group) or $20 to be able to call and schedule a same-day appt in the ED for acute problems (eg more insured pts could call in and say, "I just cut my hand and think I need stitches" to which the triage phone nurse could respond "would you like to come in in 3 hours to be seen within 15 minutes for an additional scheduling fee of $20?"

Plans like this might motivate those not paying a co-pay to cough up SOMETHING as they see the paying customers jumping in front of them in line.

Thoughts?

 

[docB]

I have rotated at different hospitals that have a person that will walk around when patients are soon to be discharged and will ask for partial / full payment for the visit. I have heard them saying "Can you just pay even 1 dollar?" I think that was something that could be implemented (paying after being in the ED and just prior to DC). It was amazing to hear people scrambling through their bags and counting out how much cash they had. I remember a few that had less than $10 and still needed to pay for the bus/cab to take them home. They would say they couldn't even afford 50 cents.

Our admitting people do this but it is widely known in our community that they don't have to pay anything. And they don't.

I wonder about two other aspects about this. Once a patient is deemed "non-emergent" but seen in the ED, can the physician still bill them as "emergent"? Will the cronies at CMS reject ER level of service? Will this open up potential for Medicare Fraud?

Press Gainey will be even more skewed than it already is when these patients who had to pay cash get their surveys? Will they be excluded?

Good question. Our belief on this is that we are required by EMTALA to provide an MSE for everything regardless of whether it's emergent or not. We don't change that evaluation based on the emergent/non-emergent determination so the charge (for those deemed emergent or the non-emergents who elect to sign in and get treatment, we don't charge the non-emergents who leave) is valid.

We were able to get our administrators to stop sending surveys to the patients who are deemed non-emergent. Since the hospital demands that we do deferral of care they were at least willing to throw us this bone.

Are you trying to raise revenue for the ED, or encourage more appropriate use of the ED by low income pts? A copay might accomplish the first goal (minimally), but will do little to address the second goal as there will always be a work-around. For example, pts will learn to say "chest pain" in order to get around the lady at the cash register, and then demand evaluation for what they really want, and it will likely be easier to just give in and give it then send them back out to pay their co-pay.

What might help with the first though would be things like a "privelige pay" or some such wherein you pay $20 to be seen faster (within your triage group) or $20 to be able to call and schedule a same-day appt in the ED for acute problems (eg more insured pts could call in and say, "I just cut my hand and think I need stitches" to which the triage phone nurse could respond "would you like to come in in 3 hours to be seen within 15 minutes for an additional scheduling fee of $20?"

Plans like this might motivate those not paying a co-pay to cough up SOMETHING as they see the paying customers jumping in front of them in line.

Thoughts?

I don't see it ever raising a significant amount of money. I see it as a possible way to get people to think twice about coming to the ER. And, as mentioned, I don't think it would actually work.

 

[namethatsmell]

Agree with the above poster--the idea of a copay for somebody on medicaid/ welfare isn't particularly pragmatic as it'd make some patients less likely to seek care...and as has been said, most in this demographic probably wouldn't pay it anyway.

That being said, maybe it's time to effectively leverage a copay in other ways from this group...how about a 20% tattoo tax with 100% of that tax going to a state fund to cover unsubsidized emergency care. Add in a 20% tax on soda and potato chips and you got yourself a stew going...

 

[VA Hopeful Dr]

Our admitting people do this but it is widely known in our community that they don't have to pay anything. And they don't.

What about tying a copay to receiving a prescription? Not even for everything, you could exempt things like antibiotics, nonnarcotic pain meds (kidney patients and their toradol).

Heck, you could just do it on narcotics and OTC meds that people demand rx's for because they don't want to pay the $5 OTC price.

 

[docB]

What about tying a copay to receiving a prescription? Not even for everything, you could exempt things like antibiotics, nonnarcotic pain meds (kidney patients and their toradol).

Heck, you could just do it on narcotics and OTC meds that people demand rx's for because they don't want to pay the $5 OTC price.

Great point. You could do this under the idea that anyone who is being discharged is by definition "stable" i.e. does not have an emergency medical condition and is therefore no longer under the mandate of EMTALA to be given care without regard to ability to pay.

The downside would be that there are a large number of people we send home on meds who would have to be admitted without them. How many people do you admit now because you know they'll never get follow up or fill their prescriptions? I send some people home who I would normally admit because their PMD is on board and assures me they'll be seen tomorrow.

For example, consider a young, healthy patient who smokes and has a pneumonia but a normal sat. If you knew he was going to have to pay a copay to get his scripts and that he might not get them would you send him out?

This idea is a bit scary in that hospital administrators are always on the lookout for ways to avoid EMTALA and put EPs on the hot seat to do it. If they decided to try this we'd be stuck implementing it the same as we have deferral of care. I think it would bite them in the ass but I see them get themselves bit regularly (and then blame others).

 

[Omiganlode]

Here in Costa Rica they have a socialized system and so there is a TON of people going to the ER for any little thing.. A lot more than I ever saw @ Jackson Memorial in Miami. It's ridiculous!!!
An ED Peds physician here, that's originally Chinese, told me that in China they make EVERYBODY pay the equivalent to about $3 when they go to the ED. She said that they figure 1. If you can't afford that, you're a terrible citizen anyways because you aren't "productive" and 2. If your poor you should be able to ask family for help and gather that amount. If you can't, then no one loves you enough to save your life.. Again, you're useless and they WON'T see you. Crazy, huh?

 

[goodoldalky]

What might help with the first though would be things like a "privelige pay" or some such wherein you pay $20 to be seen faster (within your triage group) or $20 to be able to call and schedule a same-day appt in the ED for acute problems (eg more insured pts could call in and say, "I just cut my hand and think I need stitches" to which the triage phone nurse could respond "would you like to come in in 3 hours to be seen within 15 minutes for an additional scheduling fee of $20?"

Plans like this might motivate those not paying a co-pay to cough up SOMETHING as they see the paying customers jumping in front of them in line.[GVIDEO][/GVIDEO]

Thoughts?

Decent idea but frankly this is contradictory to everything about emergency medicine. This is an emergency department, not a clinic. I don't know what the department will be like in 3 hours, and if there are more acute emergencies, your lac will be waiting. My goal is to see as many people that I can in the shortest time possible in order of who needs it most. Appointments do not fit into what is the equivalent of disaster medicine.

 

[deleted65604]

If your poor you should be able to ask family for help and gather that amount. If you can't, then no one loves you enough to save your life.

Progressives want us to live in a literal Nanny state where family has no real influence and the government educates everyone, and houses and takes care of the poor. Where there is no need for family. Once in a while, when some whiny meth-mouth complains that they don't have enough money to see a dentist, but certainly have enough money for percocet, I get personal. Have you asked your parents for money? What did they say? Do you want me to call them for you? What is their number?

We have come to live in a society where grandparents are what you fill nursing homes with, parents are what you get away from as soon as you can, and children are things that you send packing out of the house as soon as they can get knocked up and on welfare.

Who is in a better position to assess someone's personal effort, needs, and ability, a social worker or a parent?

Thirteen years ago, I picked up a hitch-hiker. He was probably 50 years old. He made the occasional buck washing businesses windows. Mostly he just lived in shelters and roamed the country. We talked for about three hours as we drove. I expected a tale of woe about bad breaks and being down on luck. What I got was a lecture from a homeless man about the merits of not working 40 hours a week and owning a home. I remember him getting out of my car and telling me that he hoped to see me in the future, and that when we met again, that he hoped I had some conviction. I was blown away by the irony of the situation.

This man lived as a parasite on society, contributing nothing, constantly trying to figure out how to extract as much as he can from those around him. His lifestyle is impossible in a society that is less prosperous than ours. He roams the country, encouraging others to live as he does, which eventually will implode if more people catch on to the ease of his life. The very person he is encouraging to slack off is the one with enough capital to actually help him.

Since then, I've come to believe that if you are a grown man/ woman and can't scrape together a few bucks for something you really need and there isn't a single friend or family member who will give you a hand-out, there is something wrong with the picture; and it isn't that the government isn't generous enough. I believe that a couple decades of work, combined with helping those around you as much as you can, should result in your ability to weather the storms of life. It certainly should enable you to pay an ER copay.

I think a copay is reasonable. I think that the progressive crowd will quickly claim that we are being heartless. The answer for them is always, always, always, get the poor taken care by the rich. Doctors are rich. So, copays won't work.

 

[glorfindel]

Progressives want us to live in a literal Nanny state where family has no real influence and the government educates everyone, and houses and takes care of the poor.

This statement is more revealing of your cultural biases than of any reality in the real world. I would amend it to read "Some progressives (most of whom are still in junior high school and haven't really fully matured as politically aware citizens) want us to live in a literal Nanny state ...."

I don't know many adults who call themselves liberal or progressive that actually want us to live in a literal nanny state, or that family should have no real influence. However, many of them do believe that the government should ensure that everyone has the opportunity to become educated, and that the poor should get some govt. assistance.

Those positions aren't very radical, and they're very compatible with the idea that there ought to be consequences for irresponsible behavior, and that meth addicts ought to make copays when they're seen in the ER.

Once in a while, when some whiny meth-mouth complains that they don't have enough money to see a dentist, but certainly have enough money for percocet, I get personal. Have you asked your parents for money? What did they say? Do you want me to call them for you? What is their number?

Sweet. As one who often sympathizes with the progressive view, I often ask them the same damn things.

We have come to live in a society where grandparents are what you fill nursing homes with, parents are what you get away from as soon as you can, and children are things that you send packing out of the house as soon as they can get knocked up and on welfare.

Sadly, this is true. But this society is the fault of progressives, conservatives, and (most of all, perhaps) apathetic, politically ignorant people across the political spectrum. It's not something progressives can take the blame for, any more than anyone else.

I think a copay is reasonable. I think that the progressive crowd will quickly claim that we are being heartless. The answer for them is always, always, always, get the poor taken care by the rich. Doctors are rich.

This "progressive crowd" that you imagine here probably doesn't exist. Most progressives would be very receptive to the idea of copays -- especially once they've shadowed us on a few shifts and seen what kind of patients we're seeing. Left-wing ideology is nuanced enough to recognize freeloaders and deadbeats.

 

[TrumpetDoc]

I feel for those that actually "do" have a hard time finding bucks for even 4 dollar scripts, let alone can/bus/ ER copayment.
But there are those who have the utter NERVE to tell me straight up they cannot afford a $4 rx and be texting on their smartphone. Ruins it for those that need it. And dunno bout everyone else's place... But the leech above is the norm, not the exception... But I'm sure that varies.


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[Flopotomist]

Decent idea but frankly this is contradictory to everything about emergency medicine. This is an emergency department, not a clinic. I don't know what the department will be like in 3 hours, and if there are more acute emergencies, your lac will be waiting. My goal is to see as many people that I can in the shortest time possible in order of who needs it most. Appointments do not fit into what is the equivalent of disaster medicine.

The emergency department is not a center that cares exclusively for disasters, it is a center that cares for acute injuries and illnesses. Thinks like a laceration would be amenable to a scheduled time within a few hours of the patient calling. Of course if a disaster happens at the time the lac is scheduled to be fixed, that would take priority, but the model of having paying patients sit in a waiting room instead of sitting in the comfort of their home waiting is just silly.

 

[GeneralVeers]

Some thoughts on a few of the issues discussed:

Co-pays can never work in the ER, because we have an entitlement society whereby you can freeload if you want. If you're an amoral person who doesn't care about your credit score, there's not a single thing any doctor or hospital can do to get an extra a dollar out of you. Additionally the fear of "missing" an emergency and the resultant litigation makes doing appropriate triage and an MSE nearly impossible. Even if you can have a nurse do an MSE with 99% accuracy, even one bad outcome can finish a doctor or a hospital.

Therefore we have to just suck it up and see everyone for free. As much as it pains me to say this, given our insane culture, medical liability and patient satisfaction we have no choice.

As far as having "scheduled appointments" in the ER, it's near impossible. Unless you dedicate a PA to seeing only "scheduled appointments" then it's unfeasible. I often get bolus of 10-20 patients coming in at completely unexpected times. Should I drop everything to go to see the "scheduled" patient?

 

[Flopotomist]

As far as having "scheduled appointments" in the ER, it's near impossible. Unless you dedicate a PA to seeing only "scheduled appointments" then it's unfeasible. I often get bolus of 10-20 patients coming in at completely unexpected times. Should I drop everything to go to see the "scheduled" patient?

What I suggest is that yes, you should reprioritize, and see the stable paying patient (customer) before the stable non-paying patient. We all get departments bolused 10-20 at a time, but most of those patients are for things that can wait 30 minutes or so while a patient "cuts in line."

We are indoctrinated into this mantra that patients are seen via acuity first, then within their assigned acuity based on the order of presentation. I say that acuity should still be the first sorting method, but within set acuity levels, there should be no reason why I can't see the paying patients first.

From a patient standpoint, if I had a minor acute ailment, eg I was a lay-person with an ankle injury and was concerned it might be broken... I would love to call the local hospitals, find out that I could be seen in 2 hours within 15 minutes of my "appointment" for a fee of an extra $20 at hospital X. I would divert my business to that hospital... The hospital that adopts such a policy would siphon off a more desireable patient pay mix.

 

[Groove]

It will never work. I wish it would, I wish it could....but it just won't. This is a topic that gets me boiling every time I discuss it with someone. I just recently went off on another forum with a similar theme. We've got problems in the ED on multiple levels. Essentially, the goal of the co-pay is to ameliorate the blatant mis-use and overcrowding of EDs with pt's that simply DON'T need to be there. The 25F with cramps that's 5 days late and wants a free UPT, the 32M with hemorrhoids and genital warts, the 42M/F drug seeker with chronic LBP that ran out of Percs 5 days ago and didn't call their PCP for a refill yet is in 10/10 pain and wants another Rx STAT, btw...you're the 3rd ED he's been to tonight, the nose bleed that has already stopped, the viral pharyngitis at 6a.m. that wants a decadron shot and a work excuse, the SCPC that's been there 20 times in the past 15 days and is always in 10/10 pain until their 3rd round of IV narcotics....talking on their cell phone the entire time and eating chips, then requests to be discharged because they suddenly feel better, the list goes on ad nauseum.

The problem is that your federal gov and state politicians WANT us to see these people. Hell, ACEP alone is arguing that the majority of presentations to ED are completely warranted. Read it yourself. They say that only 8% of ED visits are classified as "non-urgent" by the National Center for Health Statistics / CDC. I don't know about you guys but I work in a level 1 trauma center, the only one in the state, and I sure as hell see more than 8% of these guys during a shift. The problem is when you start looking up CDC and all these regulatory bodies' definition of urgent, non-urgent, semi-urgent, emergent. The definitions are made up by politicians/lawyers and non-urgent is nebulous at best and not even standardized. It's generally defined by retrospective analysis on the particular pt determining whether their injury required medical attention within 24 hours.

Let's even check out the "prudent layperson standard" in the balanced budget act of 1997 that reviews medicare/caid coverage of emergency services "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."

Are you kidding me? Essentially, if the pt "thinks" they have an emergency or pretty much any condition that requires emergency services, then they're covered in the BBA. This represents what the government sees the overarching purpose and future of emergency services in this country... a one stop shop for anything under the sun. It's Washington's dirty little secret to providing health services to virtually 100% of it's population, citizen and non-citizen alike. Want to know one of the few unpaid debts that does NOT affect your FICO score? You guessed it... medical bills. It's not factored into the debt utilization algorithm and hence...the pt you just saw and charged for your services in the ED for their minor MVC has more incentive to pay the loan off he took out or borrowed to fix his car than to pay you for your medical services. It will only affect his credit when it's sent off to a collection agency, and the hospital has to determine whether paying the agency for the 20th time on a pt who hasn't paid the 19 other times is even worth it or not.

ED overcrowding is a massive issue at the moment and I simply don't see an easy or proper solution and will have dramatic impacts on our specialty as we go forward IMO. Pt's are actively encouraged to go to the ED for anything and everything because they "will always see you", doors are always open, doc always available and most of all... they don't have to pay anything for it. We're expected to evaluate them for an emergency, perform a medical screening test, establish a legal physician-pt relationship, with no payment whatsoever for our services and absolutely NO legal protection whatsoever in case they want to sue us afterwards. You'll never get a state legislature or federal organization to define non-urgent in the context of "doesn't need to be seen in the ED" with any clarification other than a nebulous and subjective definition because they DON'T want these people being turned away. Look up some of the definitions of semi-urgent and urgent... It encompases an enormous amount of presentations that even in themselves don't need to be there. Also, any of these pt's who complain of 10/10 pain, the sickle cell pt I mentioned earlier, the gastroparetic, fibromyalgia, chronic low back pain drug seekers will never fit under any of these definitions that would help keep them out. The current system does nothing to encourage seeking health care in a responsible manner and the current system of "come one come all, we'll see you and treat you" in the ED is a massive disservice to our PCP colleagues who are losing their outpatient practices to the NP's who will soon control most of the primary care in this country within the next 10-15 years along with referral services.

We can fight it, or as I've heard from others... ah hell, just see them. It's easier, I can get them out quick, and I'm getting paid for it. Beef up ED staffing, enlarge ED's, encourage the current behavior, and burden the cost on the responsible tax payer's wallet. The problem is that the overcrowding will do nothing but water down our pt population with low-acuity, "non-urgent" (by our definition) pt's and we'll have 2 choices.... lose our "emergency" skill set, or at least some of the sharpness, or continue to hire mid-level providers like we already do that run our fast tracks. If you're a hospital administrator, or an ED director, this seems like a great choice, no? MLP's to see the low acuity, day to day crap, and the MD's can see the more acute stuff that made them go into emergency medicine in the first place. Then there's the greed... the financial incentive in all of this. MLP's are cheaper, MD's are more expensive, MD's are happy because they are seeing more emergent and higher acuity pt's, MLP's are happy because they are getting paid and encroaching on yet another specialty, hospital admins are happy because more pt's are being seen in the ED and higher admission rates, lower cost of overhead, ED directors are happy for many of the same reasons. See where I'm going with this? We're going to end up shooting ourselves in the knees just like our anesthesiology colleagues.

NP's or should I say DNP's will start to usurp yet another specialty as they've proven to do in anesthesiology. We're already witnessing a war in the OR, what's to stop that from happening in the ED? We've got CRNA, essentially NP specialty tracks. What's to keep EM ones from forming providing "EM" specialized DNP's who altogether are cheaper to perform ED services. Furthermore, if the DNP's are already controlling many of the PCP clinics/services in an area, who do you think the DNP/NP in the ED is going to refer to upon discharge??

This is the long term danger I see in our specialty and is a perversion of what I consider "Emergency Medicine" to have fundamentally and philosophically been grounded on as a specialty. We should be "experts" in recognizing, intervening, and managing most emergent or acute presentations of pathology spanning all specialties. We should also be experts in resuscitation and airway management in the ED. The current state does nothing to lower overall health care costs, only worsen them because many of these people, we've never even seen before and have one shot to determine if there is anything "emergent" going on, encouraging more shotgun workups, overuse of diagnostic studies, etc..

I love EM and wouldn't want to do anything else, but by the same token... I don't want to be an "expert" at seeing anything and everything, most of which is low-acuity and doesn't need to be there in the first place. I WANT to see emergencies. I don't want to lose my skill set. I don't want to be forced to manage pt's algorithmically in order to get paid for my services. I don't want to further encourage society to seek out medical care in a financially irresponsible manner and reinforce them in a twisted pavlovian sense that "all medical care is, and should be, free....just go to the ED....they'll always see you." Most of all, I don't want to reach retirement...perhaps even rich from the earnings...only to watch the DNP's take over MY specialty.

So, in short. I think co-pays are a great idea, but I don't think you'll ever get state or federal support to turn away pt's because of their inability to pay and your subjective determination that they are not "emergent". I wish... At best, we can fight it, and already are, at a hospital level (co-pays,FQHC/PCP referrals,etc.), but if you step back and look at the big picture.... this is really what the government wants. They want us to see all these people and they want coverage for everyone, regardless of how financially irresponsible these people are.

So, when you hear the dem's stomping their feet and salivating to tax your upper income bracket to pay for all of this stuff, simply because you "make more than everyone else", see it for what it is... redistribution of wealth.

End rant.

P.S. And don't forget to vote for Mit Romney. If you don't see Rick Perry as George W. B, prematurely re-incarnated and ready to kill the populace confidence in the GOP (all over again)... Well... you heard it here first.

 

[GeneralVeers]

I agree with everything said above, however we are powerless to fight back. Most of us are members of large(ish) EM groups that rely on their hospital contracts. The hospital has near 100% leverage over every policy and procedure that we implement. My own hospital system has mandated that every patient, whether emergent, urgent, or complete BS must be seen by a PHYSICIAN within 30 minutes. In addition they are demanding that we have high Press-Ganey scores and want to see the scores on the individual docs so they can pressure us to get rid of "low-performers".

I can't discuss money, co-pays, or inappropriate use of the ED with patients, because they all feel entitled, and if one of them gets pissed off they just write a complaint letter and an "investigation" is performed, usually resulting in a letter from my medical director apologizing for my outrageous behavior. "We are terribly sorry that the mean doctor told you to go see your primary care! Please come back to our ER for any bogus visit at any time in the future and a nice, compliant doctor will take care of you!"

Piss off the hospital in any way or don't bow to their un-funded and insane demands, and it's goodby contract. EmCare, TeamHealth, CEP or one of the other ****** of Emergency Medicine will gladly accept any contract under any hospital terms in order to present "growth" to their shareholders.

So you see, we are all on the express train to %&U^&*town.

 

[Groove]

I agree with everything said above, however we are powerless to fight back. Most of us are members of large(ish) EM groups that rely on their hospital contracts. The hospital has near 100% leverage over every policy and procedure that we implement. My own hospital system has mandated that every patient, whether emergent, urgent, or complete BS must be seen by a PHYSICIAN within 30 minutes. In addition they are demanding that we have high Press-Ganey scores and want to see the scores on the individual docs so they can pressure us to get rid of "low-performers".

I can't discuss money, co-pays, or inappropriate use of the ED with patients, because they all feel entitled, and if one of them gets pissed off they just write a complaint letter and an "investigation" is performed, usually resulting in a letter from my medical director apologizing for my outrageous behavior. "We are terribly sorry that the mean doctor told you to go see your primary care! Please come back to our ER for any bogus visit at any time in the future and a nice, compliant doctor will take care of you!"

Piss off the hospital in any way or don't bow to their un-funded and insane demands, and it's goodby contract. EmCare, TeamHealth, CEP or one of the other ****** of Emergency Medicine will gladly accept any contract under any hospital terms in order to present "growth" to their shareholders.

So you see, we are all on the express train to %&U^&*town.

Press-Ganey.... I knew I had forgotten something. Thanks for reminding me.

What a ridiculous metric for evaluation of an EP's performance. The irony is the neither Dr. Press, nor Dr. Ganey were medical doctors. Press was an anthropologist and I forget what Ganey was (googled it...sociology, ha!)....but alas, as long as PG is in bed with CMS, we're screwed. The only conceivable amount of control over the scoring that I can see is in the protocol of how it is sent/received, etc. One group had consistently low scores... Well, they were attaching it and sending it with the ED bill, 6 weeks later. Imagine opening the hospital letter to see a 10K bill with a "how happy were you with your ED visit?" When they started separating the PG survey from the ED bill, the scores miraculously rose and hospital admins were all happy again. That may be outside the control of EPs who are part of the large staffing giants as I would imagine they standardize the survey protocol...

Anyway, I wish I could disagree with you or had some sort of viable solutions but alas....I can't, and I don't. I've got nothing but wishful thinking.

 

[Redrox]

What Medicare needs to do is start making them pay for it at home after the visit, then suddenly they would stop coming if they knew their welfare check was going to get docked for "abuse".

This is the best idea I've seen yet. Not an upfront cost, so folk with no change in pockets but real need will be seen.

An automatic deduction of the government check received. $20 taken out of social security, or disability or some other type of payment will have only a negligible effect of deterrence on our low use community patients but will have one for frequent flyers, I hope.

This would be not just another bill for them to dodge or hem and haw in paying. Have a sign at the front door letting patients know this will happen.

Anybody see much of a legal or political downside for this?

 

[Groove]

Anybody see much of a legal or political downside for this?

Other than CNN posting a headline story about little 'ol grandma who can't eat 3 meals a day or buy toothpaste because her welfare (and I mean welfare in the broadest sense of the word, after all... social security is essentially welfare) payments are being cut due to medical bills 2/2 illness she has no control over and required an ED visit? Breeder with 7 kids who can't feed her children because her checks are being cut due to her ED visits for <insert anything>? You could drudge up a million "egregious" stories and the media would have a frenzy and have the policy makers lined up in front of firing squads and only up for re-election...post mortem. After all, What voter is going to elect an official that is trying to rob them of "free health care" ?

Who wants to defend the egregious misuse of the ED or EPs complaining about being sued for providing free services? After all, we're all supposed to be rich, right? We should all want to provide free care for all people, out of sheer altruism if anything. What selfish pricks we all are for even beginning to complain.

Physicians gain little sympathy from the majority of the public because of their misunderstanding of health care, feeling of entitlement as GeneralVeers aptly pointed out, and left over... Marxist perceptions, for lack of a better phrase... that physicians are the bourgeoisie of society while everyone else is the proletariat and we're out to make them even poorer and make ourselves more rich.

Other than that, I see no problem whatsoever with such a policy... Let me know before you implement it though so I can buy stock in Kevlar and bulletproof glass.

 

[Redrox]

Other than CNN posting a headline story about little 'ol grandma who can't eat 3 meals a day or buy toothpaste because her welfare (and I mean welfare in the broadest sense of the word, after all... social security is essentially welfare) payments are being cut due to medical bills 2/2 illness she has no control over and required an ED visit? Breeder with 7 kids who can't feed her children because her checks are being cut due to her ED visits for <insert anything>?

Forcing somebody to pay a very small part of bill after service is far more palatable than denying care. The only possible argument against this is to state that healthcare should be free and universal.

With a Republican congress and potentially a Republican president, (whatever you're feelings on this possible outcome) 2014 could see another healthcare bill. With the tea part mania on personal responsibility, shouldn't be another opportunity to slip something in for the benefit of patients and providers like this for years.

This is a long shot, but I seriously foolishly hope that this time around the few healthcare lobbies not representing the insurance industry can have a focused plan and push something like this through.

Experimentation at the state level is going on now. They're doing a crappy job of course, with Cali balance-billing, Washington's list of non-emergencies and Pennsylvanias preposed plan to offer incentives to patients to go to other hospitals. But at least this signals to me that perhaps politicians are open to experimentation. This could be the time for something new on a national scale. At least worth a try, worth a little brainstorming.

 

[GeneralVeers]

Forcing somebody to pay a very small part of bill after service is far more palatable than denying care. The only possible argument against this is to state that healthcare should be free and universal.

How do you "force" someone? Collections agencies have very little recourse to pursue if someone doesn't care about their credit score. Generally if the bill is less than $1000 they aren't going to take the person to court either.

The only way to reduce inappropriate usage of the ER is to enact a liability-free MSE, whereby if you meet your institutions (ACEP's) standards for an MSE, you cannot be sued if there is a bad outcome.

 

[emclark]

..

 

[Redrox]

I was referring to Dr McNinja's idea of having the $20 taken from their subsequent governement check (social security, disability, welfare). But, yeah, now that I think of it, that'd be too much paperwork across multiple agencies for it ever to be workable.

 

[TrumpetDoc]

The only way to reduce inappropriate usage of the ER is to enact a liability-free MSE, whereby if you meet your institutions (ACEP's) standards for an MSE, you cannot be sued if there is a bad outcome.

exactly. And this SHOULD definitely be the case.
Mandate us to do the work, give us due protection.
However, I know it will likely never happen....


I know, let's "occupy" something!!!!



Sent from my iPhone using Tapatalk

 

[Heimskringla]

I had a deep laceration requiring stitches. It was bleeding profusely after an hour, so I gave in and went to the ER. I was a bit surprised to learn that my insurance company charges an $50 copay per ER visit.

I take care of an older parent and reduced the hours I work to attend a respiratory therapy program, so the sudden requirement for $50 wasn't as trivial as it was when I was billing 30-40 hours a week.

I don't think co-pays will keep people with no insurance or routine access to medical care out of the ER. We've opened a few community clinics here which have cut down on the use of the ER for non-emergent situations.

 

[telenurse]

$50 for a ED copay is excellent...it is $200 for the crappy healthplan my hospital provides its workers. I was just seen for the dreaded female with RLQ pain workup that all ED physicians must hate. Luckily, I still have my appendix, unfortunately, I ruptured one heck of an ovarian cyst, (those suckers hurt...knocked me over when it popped). If you think of the time/education the MD spent with you, the nursing hours, the unit secretary, the supplies/meds used, the paperwork....$50 is nothing.