Upfront payment for non emergent conditions

Altra, BSN, RN · Nov 16, 2011

The current system rewards trivial visits, and encourages people to use the ER, rather than seek out options.
...
I think the real question is whether a hospital ER has the responsibility to provide free unlimited care. If you work in an ER, you know this is fairly common. It should be common in our current structure, as it works well for the recipients- at least from their perspective. The problem is that it is A- a pretty expensive way to provide care, and B- can interfere with the ability of an ER to treat emergent pt's. ...

Totally agree. An exam by a mid-level provider satisfies both EMTALA and clinical common sense. Patients with symptoms with the potential to be serious will be retained for further evaluation. Others will be streeted, having gotten their first education on what other resources are available for non-emergent complaints.

Guest219794 · Nov 17, 2011

Let's be clear about what we are talking about.

Nobody is suggesting a hospital turn away emergencies. There is no way risk management will allow anything but the most conservative approach to screening.

I have good health insurance, and a good job. I have a good relationship with my PCP.

If I have a minor, or chronic problem I cannot be seen immediately. I will have to make an appointment, and wait. If I showed up at the office for something minor without an appointment, they would ask me to come back on my scheduled appointment.

Now, I could go to the ER and be treated immediately, but that would cost me a lot of money. My insurance company will penalize me for non-emergernt ER use.

Since I make the financial decision to defer this kind of care for myself, why would I not make the same decision for somebody else?

hiddencatRN, BSN, RN · Nov 17, 2011

Since I make the financial decision to defer this kind of care for myself, why would I not make the same decision for somebody else?

Because there really isn't the infrastructure to handle the primary care of all of our patients who are without insurance. We have free clinics in my city....and they have a minimum of a 3 month long waiting list. You wait a couple of days to get seen by your doctor

"Look at it this way: If the money was coming out of your pocket, (it actually is) would you set up the current system as it is, or would you find a more cost effective way to treat non emergent patients with no money or insurance?"

I don't think those have to be the only two options, to leave things the way they are or to refuse care to non-emergent patients who can't pay. But if we're looking at those as my only options in a game of "would you rather," then no, I'm not comfortable requiring prepayment for non emergent conditions, given the current state of my city's public healthcare availability. I would be surprised if my city's situation is completely unique.

Murse901, MSN, RN · Nov 17, 2011

Because there really isn't the infrastructure to handle the primary care of all of our patients who are without insurance. We have free clinics in my city....and they have a minimum of a 3 month long waiting list. You wait a couple of days to get seen by your doctor.

The ED is not designed to be a part of the primary care infrastructure, and people who abuse the ED are the reason that policies like this are put into place. Some people don't want to just suck it up and buy some Nyquil and cough drops when they have a sore throat. Some people don't want to go to Walmart and spend $10 on an EPT when they can go to the ED and get it done for "free".

The large majority of people that abuse the ED never intend to pay. Again, they are the reason that these policies were put into place. If there is no money coming in, then guess what? You and I don't have a job, and there is no healthcare for ANYONE.

We do need more primary care available. No one is going to argue against that. But, using the ED for primary care makes about as much sense as calling the police to come over and watch your dog while you're on vacation. Sure, they're more than capable of watching your dog, but is it really the right use of resources for a non-urgent issue?

Guest219794 · Nov 18, 2011

because there really isn't the infrastructure to handle the primary care of all of our patients who are without insurance. we have free clinics in my city....and they have a minimum of a 3 month long waiting list. you wait a couple of days to get seen by your doctor
"look at it this way: if the money was coming out of your pocket, (it actually is) would you set up the current system as it is, or would you find a more cost effective way to treat non emergent patients with no money or insurance?"
i don't think those have to be the only two options, to leave things the way they are or to refuse care to non-emergent patients who can't pay. but if we're looking at those as my only options in a game of "would you rather," then no, i'm not comfortable requiring prepayment for non emergent conditions, given the current state of my city's public healthcare availability. i would be surprised if my city's situation is completely unique.

you make good points, and i agree alternatives need to be developed.

the question remains as to whether the er should provide free, unlimited, services, on demand. for example: pt disagrees with the dx given by a specialist come to the er for this chronic problem. could this person be screened out?

btw- as much as i agree with the need to change the current system, i disagree with the term "er abuse" used by many. the "abusers" are making use of the system set up by others. the key to changing this behavior is not to blame the users of the system, but to change the system. using the er to get free care for minor problems is perfectly rational. allowing a hugely expensive system which yield marginal results to persist, is not.

maelstrom143 · Nov 18, 2011

BTW- As much as I agree with the need to change the current system, I disagree with the term "ER abuse" used by many. The "abusers" are making use of the system set up by others. The key to changing this behavior is not to blame the users of the system, but to change the system. Using the ER to get free care for minor problems is perfectly rational. Allowing a hugely expensive system which yield marginal results to persist, is not.

There are many things that are imminently "rational." That does not make it right.

It is easy to excuse one's bad behavior by saying, well, it can be done so we might as well do so. Right is right and wrong is wrong and people ought to have the common sense to know that without having it shoved down their throats.

Abuse of systems occurs because systems are set up with good intentions and then the parasites crop up who think the world owes them something and therefore they work at finding loopholes to get what they want without paying for it themselves. As a result, those people that truly need the services available end up waiting inordinate amounts of time or even not being cared for because the systems in place are overburdened by those that do not really need the extra help, but what the heck? We might as well take it...IT'S FREE! :uhoh3:

There are people out there that really are sick, in need, that are in dire need of help and care. For those people, the system is in place. Unfortunately, the parasites are oftentimes faster, smarter, meaner and so get there first and drain the little bit that has been set aside for the truly needy.

Well, gonna get off my soapbox now.

My DH says it is "survival of the fittest." I say, fine, let's go back to Hammurabi.

TLSpaz, ASN, RN · Dec 8, 2011

So just curious to hear some other opinions of this. Our hospital is considering a serious overhaul of its ER practices due to the upcoming reductions in Medicaid. All patients presenting with any complaint are to have a medical screening exam (as per EMTALA) performed by the mid-level provider stationed out in the triage area. If, according to the medical screening, the person does not have an emergent condition, an appointed person (new "care finder" position) will give the person a choice of either being seen in the ER but they will have to pay upfront for the care OR they will be provided with the names of clinics where they can go to be treated. According to EMTALA, the ER is not required to treat anyone other than those presenting with emergent conditions or in active labor. I work in an inner city not for profit hospital where it seems the majority of the patients are uninsured or on Medicaid. It is also a rather poor area and of course people frequently use the ER for routine medical problems. I was just wondering what anyone else thought of this idea.

The ER that I just recently resigned from has a very similar policy in place. I do not have too many positive things to say about my former place of employment, but this policy is a good thing, in my opinion.

TLSpaz, ASN, RN · Dec 8, 2011

. So the difference is that the patient gets told "yeah, looks like strep, pay now or go home" versus "yeah, the 5 minute rapid strep confirms strep throat, here's your scrip for abx"? Considering the fact that the rapid strep could have been done while the mid-level was seeing the previous patients waiting to be screened, it doesn't seem to me like much of a time saver (freeing beds and improving patient flow) or a money saver.

I don't ever recall a pt with chief complaint of "sore throat" being relegated to RCRP status (my facility's designator for pts triaged as "routine").

I even remember reading a PA's documentation in one chart of a pt who had been initially designated RCRP, that went something like this:

Due to pt's presenting complaint of (fill in the blank), I cannot, with initial MSE, rule out a diagnosis that is a potential life-threating condition for this patient.

This would be documented in response to the pt being triaged initially as a Level 5. If the pt needed a rapid-strep, then the MSE would reveal that the pt could not be just streeted without further evaluation. Another way to say this: If a pt required a rapid strep, they would automatically get to stay and be seen.

I have also seen this before: CC quote: " I came from out of town to visit family and I forgot to refill my medication. I need to get a refill today." Guess what? MSE revealed no presence of an emergent medical condition. Pt was asked to pay, and lo-and-behold, AGREED to pay right then! Had that pt refused to pay, we would have offered a list of providers willing to work with those needing financial arrangements.

sirendip · Dec 12, 2011

I guess I wonder how exactly a mid-level care provider doing an exam that complies with EMTALA will make things go more quickly. These exams will still have to happen somewhere, and this sounds a lot like urgent care to me, which we have in our ED. So the difference is that the patient gets told "yeah, looks like strep, pay now or go home" versus "yea'sh, the 5 minute rapid strep confirms strep throat, here's your scrip for abx"? Considering the fact that the rapid strep could have been done while the mid-level was seeing the previous patients waiting to be screened, it doesn't seem to me like much of a time saver (freeing beds and improving patient flow) or a money saver.
I would love people to start making better use of the ED: patients that cost the hospital money aren't job security when the hospital goes out of business or closes their ED, and I get plenty annoyed when people get huffy about when the doctor will hurry up and get to them to see their ringworm or hooha discharge or whatever, but I think making primary care truly accessible has to happen first. We have patients who come in who tried to get visits with their PCP who were told to go ahead and go to the ED because the doctor's office doesn't want to/can't deal with the sick visit volume, and our local free clinics are already busting at the seams, and primary care doctors aren't earning wages competitive with other specialties. EMTALA frustrates me sometimes, but when I look at the larger issues within the healthcare system....I'm glad we don't turn people away.

Yeah you hit the nail on the head. The problems in our healthcare system have forced the ER to be the Gateway of care for poor and indigent at all levels. Even more so now that unemployment as skyrocketed making keeping affordable healthcare out of people's reach. We have a fast track that helps lessen over crowding in the inner city er where I work. I know we have a problem with payor mix where I work. I also think we do have to think out of the box to fix this problem. As long as the screening exams are performed with accuracy, I don't see most providers being vulnerable to litigation. (Anymore than we already are!!!!) :nurse:

LindsayRNer · Jan 25, 2012

I work at a busy ER (stroke & cardiac center) and we have implemented this. The non-urgent cases are triaged by the triage nurse, then the chart is given to the PA or NP, and they decide if the patient needs further eval. The PA and NP in the state of NV cannot work independently; everything must be in collaboration with the MD or DO. It's ultimately the doc's decision.

My last shift I worked in rapid treatment & the most ridiculous thing I saw was a woman who tripped and busted her acyrlic nail who complained of soreness in her finger. Normal people don't go to the ER for a broken nail. I'm not a doctor but if ANYONE believes that this is not a form of ER abuse, I don't know what is.

Next, a woman who spent all her money in the casino was complaining that she didn't "eat well today". Instead of blowing the money on slots she probably should have bought a 2 dollar breakfast, or better yet, ask the casino to comp her a meal.

An older man forgot his viagra at home (out of state) and wanted to have sex, he paid. I SWEAR!!!

Someone in their late 30s didn't have a bowel movement x1 day. I think they evaluated this one and sent them home, but the pt did not try an OTC laxative, did not try increasing their activity, did not try drinking more water, did not try increasing fruits or veggies in their diet.. or even waiting another day to poop!

We don't charge our drunks for our beds, but you know what they do? They drink, pass out on the sidewalk, someone calls 911, they're brought in.. they sleep, they wake up, they yell profanities directed at you (you ugly cun*), they leave.. they panhandle, and the cycle starts ALL over again. I see the same people every week, if not EVERY shift and I am not exaggerating.

JulieL · Jan 26, 2012

Esme & others,

Really informative! Thank you for taking the time to be so thorough. I am going to check out the link you provided. We had 6 hours of lecture this week about emergency room care, and this was not even mentioned.

MrsNJTransplant · Jan 27, 2012

I am always so interested in this and the general public's knowledge of traige and the Emergency Room world. I work in a very busy trauma center (as a tech, in nursing school) and can't help but wonder why there isn't some explanation of how triage works. Can't they print it up on the back of the admission forms or even better yet have the clerk give an explanation of this? I guess it wouldn't matter much anyways.

With a tighening budget, our fast track area gets shut down on night shift so even the low acuity peeps get thrown into the general pool.

A few shifts ago a young woman was very upset for waiting a few hours for her flu-like symtpoms to be addressed. I felt for her, I really did. She was alone and looked very tired and run-down. So as she was cursing at me to find a Dr or she was going to write an email to complain, I attempted to explain the concept of triage. Well, that went downhill very quickly!!! I was only trying to help. And as there were three stretchers (with sick pts!) lined up behind me waiting for assignments to a room, she continued to curse me out and tell me I was an @#$&*@#^ for saying she wasn't sick!!! :uhoh3:

Ughhh, I never said you were not sick. I said the MOST sick get seen first in the ER. Which is why there is no Dr over here in your little bay!!!!! :thankya: