Some Finding No Room at the ER Screening Out Non-Urgent Cases Stirs Controversy By Ceci Connolly Washington Post Staff Writer Monday, April 26, 2004; Page A01 DENVER -- It's not the heart attacks or stabbings that alarm Norman Paradis. It's the minor maladies, the daily deluge of coughs, colds, toothaches and even hangnails that clog his emergency room. As the provider of last resort, hospital emergency departments across America have for decades accepted thousands of truly non-urgent cases and swallowed the cost. For the most part, the patients have nowhere else to go, no insurance and no money. That is starting to change. University of Colorado Hospital, where Paradis works, is leading the way on a controversial solution -- weeding out the people with bumps and scrapes so it can devote more time and resources to serious, life-threatening traumas and, also, to paying customers. Officials here say its 15-month-old system of medical screening, or "triaging out," could go a long way in easing the financial strains that have forced hundreds of emergency departments to shut down in the last decade. But many in the health care profession call it a callous, greedy and shortsighted maneuver that puts a greater burden on neighboring clinics and hospitals -- all at the ultimate expense of the working poor. Under the new policy, University hospital demands partial payment up front from non-emergency patients who seek treatment in the ER. For some, including Medicare and Medicaid beneficiaries, the fee is a small cash co-payment; insurance pays the rest. For the uninsured, however, the charge can be a few hundred dollars -- money many don't have. So they leave, toting a list of low-cost clinics in the area. Rather than being a remedy, many argue, medical screening is a symptom of much of what ails America's health system. "It's an incredibly mean, nasty time to be in medicine," said Mark Earnest, a general internist at University and vice president of the Colorado Coalition for the Medically Underserved. "There is not a consensus on how we are going to take care of people, and the result is everybody having to worry about their own survival." The experiment at the Denver hospital and similar efforts in Indianapolis and Houston cut to the core of some of the thorniest problems in health care today. With about 44 million uninsured Americans, a record number of patients are flooding emergency rooms, a trend experts say is unwise from both a medical and economic perspective. ER care is both the most costly and least effective at treating the sort of chronic problems that claim the greatest number of lives each year. In 2002, U.S. hospitals provided $22.3 billion in uncompensated care, up from $18.5 billion in 1997, according to the most recent data from the American Hospital Association. In the past, hospitals have made up some of the deficit by charging insured patients higher fees, a cost-shifting trick that in medical circles is dubbed the Robin Hood model. But that money is disappearing, too. "We can't do everything for everyone, so what are we not going to do?" asked Paradis, who, as head of University's emergency department, implemented the screening policy in the fall of 2002. Other hospitals, clinics and private physicians find ways to limit care covertly, Paradis contends, while "we are overt. It's rational rationing." Stop at the Financial Desk On a recent gray Monday morning, a slow trickle of patients passed through the 11th Avenue emergency entrance of the University of Colorado Hospital. Among them were Molly Turner and Debbie, a 45-year-old woman who asked that her last name not be published because her insurer might object to her ER visit. Both women had endured a miserable weekend: Turner afflicted with a cough, sore throat and slight wheeze, Debbie with painful hives she feared might be chickenpox. Both women were seen by the top doctor on duty, Norman Paradis. And both cases, he ruled, were "non-emergent" -- not serious enough to require immediate care. Under the new policy, he explained to each, the next stop was the financial desk, where patients may pay to stay for treatment or leave and get a much smaller bill in the mail for the screening. From there, the two women took different paths. Turner, 27, a mother of three who sells sod at a local farm, dropped her health insurance when the price hit $390 a month. Informed she would have to pay the hospital $250, she opted to go home and tough out what Paradis said were seasonal allergies. "You get what you pay for," she said with a shrug afterward. "If I wanted to pay $250 I'd have had the full-blown workup. But he's telling me it's not necessary, so I'm comfortable with that." Still, Turner was unsettled that Paradis reached his conclusion after just a brief chat and a listen through the stethoscope. "I wanted to say, 'Are you sure? You don't want to do any tests?' " she said. "But he's the doctor." For her half-hour visit, Turner would get a $50 bill and a list of primary care clinics in the area. The health insurance provided through the employer of Debbie's husband requires a straight 20 percent co-payment with no deductibles or up-front charges. Because she doesn't have a primary care physician, she decided to stay -- and was pleased with the service. "I've been to emergency rooms where there are crying babies and the whole drama," she said, seated on an exam table. "I'm amazed how quiet it is." On average, one-third of the care provided in U.S. emergency departments is "inappropriate," several studies have found. At Houston's Memorial Hermann Healthcare System, the stubbed toes, twisted ankles, leg pains, earaches and abscesses account for nearly 120,000 of the 345,000 visits each year to its eight acute care hospitals, said Tom Flanagan, vice president for emergency services. In an attempt to deal with the crowding, the hospitals instituted a triage system similar to Denver's University hospital, though there is no charge for the initial screening. "The resources for caring for those patients are very limited," said Brent King, chairman of the emergency medicine department at the University of Texas at Houston Medical School, which is affiliated with Memorial Hermann. "Under the current market conditions, no one can stay in business if they don't somehow limit this load of patients." At University, Debbie's rash and Turner's allergies are precisely the sort of cases that used to jam the emergency department. In the past six months, ambulances have delivered three hangnail cases to the ER; another person made 165 visits in one year, Paradis said. "That kind of behavior wrecks the system," he said, and used to force the hospital to divert ambulances to other hospitals hundreds of times each month. Since beginning the screening, emergency room visits have dropped 20 percent, and diversions have been almost nonexistent, Paradis said. But the desire to redirect minor cases to more appropriate treatment facilities only goes so far. In a perversion of the system, insured patients such as Debbie are welcome to stay, no matter how trivial the problem. "Because of her insurance, our institution will make money on her visit," Paradis said. "The charges on those cases help us treat the indigent cases." A Doctor Comes Around When University began screening ER patients, Kristen Nordenholz was "one of the most recalcitrant and angry" professionals on staff, as she put it. After working five years for the Indian Health Service, which provides comprehensive care for all, she found that ER triaging was "the opposite of what we are trained to do as physicians." Yet Nordenholz has come around, in large measure because University has given doctors wide latitude in the screening process. "Many people come just to have their fears alleviated, and they don't understand how expensive emergency medicine is," she said. Now, ER patients "are getting to see a senior doctor, usually within 20 minutes. That's not bad care."