New ED drama? Hospitals demand upfront fee for nonemergencies

By Kevin B. O’Reilly
American Medical News, December 3, 2012

(A small) but growing number of hospitals give patients whose problems are deemed nonemergent a choice: Pay an initial fee to get the problem treated in the ED, or seek care elsewhere. The fees range from $100 to $180 for uninsured patients, or the relevant co-pay or deductible for insured patients.

Hospitals implementing the pay-first policy say it complies with the Emergency Medical Treatment and Active Labor Act because all patients receive the federally required medical screening regardless of ability to pay. It is only after a patient’s condition is deemed nonemergent that upfront payment for further treatment in the ED is discussed.

Yet many doctors interviewed for this article found the growing trend alarming. They said it unfairly targets patients with poor access to primary care and is unlikely to alleviate ED crowding because nonurgent problems make up less than 10% of visits. Emergency physicians added that the policy could result in tragedy, because some seemingly nonemergent conditions quickly worsen, and because some patients with life-threatening problems may wrongly decide to steer clear of the ED to avoid pay-first fees.

The pay trend is severely misguided, said Arthur L. Kellermann, MD, MPH, who served on an Institute of Medicine emergency care panel and now is a health policy researcher at the RAND Corp., an independent nonprofit think tank.

“People don’t go the ER as a recreational event,” he said. “If you tell me you have an urgent care clinic or walk-in clinic or other places where these people can go straight to, then OK. But to tell someone to just go away if you don’t have $150, you have to be ignoring the fact that if they had somewhere to go they wouldn’t be there in the first place. And you have to be damn sure that this patient doesn’t have a more serious problem. This is putting a Band-Aid on a gunshot wound.”

“There are truly people who come to the ED with something very benign, and it ends up being a major medical issue,” said Patrick O’Malley, MD, an emergency physician in a suburb of Columbia, S.C. “Determining who those patients are right at the front door is difficult.”

The pay-first policy appears to be aimed at discouraging uninsured patients from visiting the ED, said Leora Horwitz, MD, assistant professor of general internal medicine at Yale University School of Medicine in Connecticut.

“A much better solution to this kind of problem would be to incentivize primary care doctors to provide the care that’s needed, to have evening hours, weekend hours, and to have more urgent care centers,” Dr. Horwitz said. “There are many ways to improve access for patients without barring the door of the ER as your solution.”

Over half of emergency department (ED) visits are truly urgent or emergent and should be seen within minutes. About 35 percent are semi-urgent and should be seen within a couple of hours. Only 8 percent are non-urgent and could be seen the next day. Which of these patients should never be seen in the ED?

If you assume that patients are fully capable of assessing the urgency of their own problems and and that triage nurses are fully capable of never making a judgement error, then perhaps the 8 percent who are non-urgent should be seen by their primary care professionals at the next available appointment. But such an assumption is a stretch since the true urgency often cannot be determined with absolute certainty until there is a full assessment of the problem.

Maybe that head cold is an acute bacterial sinusitis, which could lead to meningitis or an abscess with sepsis. Maybe that gastrocnemius strain is thromboplebitis, which could result in a pulmonary embolism. Maybe that migraine is a rupturing berry aneurysm, which… well, you know. Then again, maybe these really are minor, non-urgent problems that do not need assessment in the ED.

How do you decide that? Do you have the triage nurse make a decision to turn the patient away at the front desk with no further ED evaluation? That can be a problem if the nurse’s initial screen misses a serious problem, which is certainly possible, even if infrequent.

The answer is easy. In this age of consumer-directed health care, you do not turn anyone away. Instead, you require the patient who seems to have a non-urgent problem to use their health care shopping skills by requiring a payment up front. Thus the ultimate decision is not left with the triage nurse but rather is left with the least qualified individual in the ED – the patient.

Some patients will make the wrong decision – bad policy. This is overkill, perhaps literally.

If a local ED is truly overburdened with routine medical problems, the proper management should be to adjust capacity in the health care system. If primary care services need to be extended to evening and weekend hours, improve capacity so that can be done. If the void can be filled with a free-standing urgent care clinic, then establish that. The ED itself could be expanded to include a wing for less urgent problems, staffed with a nurse practitioner of primary care physician, if appropriate for the community. The marginal cost should not be much different from a free-standing, off-hours clinic, if that.

Under a single payer system, some adjustments in capacity can be made by administrators of the global budgets for the facilities. More extensive changes might involve separate budgets established for capital improvements. But creating financial barriers to care runs the risk of having the patient decide to forgo beneficial health care that just might possibly be lifesaving.

If the ED is crowded with the worried well, fix the system. Don’t kill the seriously ill patient hidden amongst them.