ER's Turn Non-Emergencies Away?

[mwboswell]

The below article appeared on the website of a local news station in Rock Hill SC. Some people in the community have varied opinions about this. For those of us "in the business", what do you think about this kind of policy? Do you think it will actually make a difference or is it just bad public relations or giving people a mixed message about a hospital's concern for it's community? What if a patient has no insurance and can't afford a doctor's office visit, where do they go? What do you think?

Local Hospital's New Policy Of Turning Patients Away Upsets Some

Posted: 6:28 pm EDT May 12, 2009

ROCK HILL, S.C. --

Diana Burgess of Rock Hill went to the emergency room at Piedmont Medical Center last month with severe pain in her side."The doctors came in and just basically said they weren't going to do anything for me," she said. The ER doctors determined that the pain Burgess was suffering was not an emergency and didn't require immediate care. President and CEO of Piedmont Medical Center Charlie Miller explained the policy this way: "it is an emergency room, not a primary care clinic." "We think it's had a positive impact on wait times," Miller said. "Two-hundred to 250 people a month are leaving to see their primary care doctor instead." Hospital officials also said patient care is better when they can see a doctor outside of the hospital and form a relationship, rather than using the emergency room as their doctor. However, people like Burgess, who doesn't have any health insurance, said she can't afford to see a regular doctor. "I just left there crying," she said. "I was hurting too. I was really feeling bad. "Miller said the hospital does what is required by law, which means doing a medical screening for every person who comes into the ER. Then doctors determine if their condition requires immediate emergency care.

[mwboswell]

If it is not an emergency and I "DO" have insurance will I be treated any differently?

You shouldn't be treated any differently.

They would probably ask you for your "ER" co-pay that your plan has as well as any deductibles.

Remember, even if the self-payor pt doesn't have an emergency, BUT they pay the $200-$250 up front, then they can get treated.

[mwboswell]

i don't think there will ever be anyone happy with the ER policy no matter what. it is kind of sad that it had to get like this

the whole health care system seems a mess to me...

just a thought :-(

I don't think that it "had to get like this"..."This" was the way it was intended to be.

At least that's what the Federal EMTALA standard guaranteed - that everyone would get a "medical screening exam" (not necessariaily treatment) to see if they had an "emergency medical condition".

If no "emergency Medical condition" exists, the obligation for further treatment ceases.

However, we, as a system have allowed the "treatment" to go on despite no "emergency medical condition" existing.

I'm not against treating non-emergencies, I'm just stating the original intent of EMTALA and the purpose of the MSE.

[mwboswell]

If it's not an emergency your insurance may not pay. My husband recently went to the ER for dizziness and we got a letter from our insurance company saying it was not deemed an emergency and they would not cover the bill.

This ticked me off because I am an ER nurse and I see all these freeloaders that come in for minor complaints and never pay a penny. My husband who was too dizzy to walk and has insurance couldn't get covered. I've never been so mad. I tried to appeal it but didn't get anywhere.

I would appeal that to the hospital billing department. Point out that your insurance won't pay for "emergency" servcies and if they can re-code it and re-submit the insurance might pay it. Trust me the hospital/ED wants their money. If you make it clear that they are more likely to get the reduced fees from the insurance company if they re-code it versus if you have to pay out of pocket - they "may" just work with you.

[mwboswell]

There are not enough free or sliding scale clinics around. Then if perchance any workup is needed it is still faster done in an ER no matter how crowded it is. Then there are the local doctors who send their pts to the ER knowing we will get all these tests done quickly regardless of ability to pay. And get these patients admitted for them and they dont have to the work. It is the way our world works untill we get United Health Coverage for all.

...oh really?

Do you really believe this?

Please refer to the VA health care system as your prime example of "universal payor" healthcare.

[mwboswell]

Maybe it would be good if we could have a better referral system? Is it feasible for the hospital to work with the other clinics in the area to refer out non-emergencies instead of refusing care? Maybe give the patients options instead of denials?

Good point.

This would be the ideal situation, AND, I believe that any ED that incorporates the "non-emergencies-pay-first" policy, SHOULD have this type of referral mechanism in place.

The ED's on military installations do just this (if their service lines are big enough). The ED triage nurse will check you, assess for an emergency and if not, they begin calling around to see where you need to go and get you an appointment time/slot (family practice, flight medicine, sick call etc.)

But of course that's easier done in the military system especially with their differences in liability and malpractice. But when you see it work, it works well.

[mwboswell]

We have a system coming down that I expect to start rolling out in the next year. We'll be building an interdisciplinary team that will review ED records and look for our major offenders and attempt to get them tied into more appropriate resources including PMD coverage. Part of it will be holding the line on narcotics and more aggressive use of medical screening exams for frequent fliers.

.

I "know" of a similar system already in place. It is headed by a "case manager" full-time RN. Her sole purpose is to identify "frequent flyers" or potential "ff's" and intervene while in the department assessing their long term needs and starting to work with them to find a "medical home". This also starts the process of identifying the pt with potential follow up "issues" and ER recidivism (sp?). From what I "hear" it's working great and has full buy-in by the medical directorship and nursing admin. Even got one long term FF onto HOSPICE care (as he was end-stage already) and this pt definitely benefitted by aggressive/apropriate pain control, better than he ever got during his twice weekly ED visits! He has passed on since then, but his final weeks/days had a whole lot less suffering and his passing was not a liability laden event which it could have been if he continued to frequently court the ER services.

[LHH1996]

mwboswell...you misunderstood and only took a piece of my post and ran with it. I MEANT by "it had to come to THIS" was, that people who abused the ER are why they had to make such policies in the first place. Hence the saying, "one bad apple spoils the whole bunch"

i totally agree that people should not come to the ER for non emergancies..i guess i went off on a tangent because this subject reminds me that basically the whole health care system is a mixed up mess if you really think about it.

[Lunah, MSN, RN]

We have a similar case manager set-up in our system to identify the patients who are falling through the cracks. We work very hard to get patients to the appropriate follow-up, but sometimes they really just want to be seen in the ED, so they don't bother with follow-up, even if it's to our community health center that bills patients on a sliding scale basis.

I'm sure the scenario in the article was more like a "real" ED visit -- the patient was triaged and placed in a patient room, and was then seen by the provider. The article presents it as if the patient was met at the front door by the doc and told to go away.

I had a patient yesterday who was 9 years old, brought in by mom because he bumped his head. No complaints, no symptoms, not even a mark on him! He was seen by our provider, who explained to his mother why she wasn't going to order a CT head, and we discharged them with CHI instructions and told her what to watch out for. They left happy. But we did no more for her than the docs did for the person in the article ... of course, it's all in the presentation. In the article, they stated that they weren't going to treat her because it wasn't an emergency (according to the patient, anyway), and we told our patient we didn't need to do any tests at this time, but here is what to look for that would constitute an emergency.

Some of our providers are holding back on prescribing narcs, too. We try to hook those folks up with pain management.

[mwboswell]

mwboswell...you misunderstood and only took a piece of my post and ran with it. I MEANT by "it had to come to THIS" was, that people who abused the ER are why they had to make such policies in the first place. Hence the saying, "one bad apple spoils the whole bunch"

i totally agree that people should not come to the ER for non emergancies..i guess i went off on a tangent because this subject reminds me that basically the whole health care system is a mixed up mess if you really think about it.

Your first point is taken.

But your second point - I don't share.

I don't mind people coming to the ER for non-emergencies...so long as they can pay for my service and time. I'm just guessing here, but I'm thinking "non-emegencies" pay our labor/operating costs a lot more than "emergencies" do....

A LOT OF US would be out of jobs if only "emergencies" came in.....

Go figure.

[RedSox33RN]

I understand your point there, M Boswell, which I guess is why most ED's have Fast-Track areas now. It wasn't long ago that these weren't even thought of. Those are definitely non-emergent pts. Like you, I don't mind them coming and being seen there - they know the wait may be longer, but I don't want them taking up my last bed in the Main ED. The big question is if they will pay or not.....

It really chaps my rear to hear patients tell me they can't afford their b/p meds/diabetic meds/tylenol for fever or pain, then see the cigarettes (or smell it on them) in the Coach purse, $300 Blackberry with bluetooth in the ear, kids playing PSP in $100 sneakers, hair and nails professionally done....I know we've all seen it. And yes, I've discharged many in w/c and brought them to the parking lot and seen the spouse's luxury SUV with spinner rims and expensive tires. It is all THAT kind of stuff the makes me mad. If you can't afford to pay me, sell that stuff.

I do like the idea of evaluating those pts seen in the ED on a frequent basis. I question whether a lot of ours, if time was taken to set them up with a PMD or clinic, would comply. I sometimes think we, because of our new and improved "committment to customer service" are part of the problem. Some docs will tell pts they are using the ED way too much, but most just treat-n-street, no matter how many times the pt comes in. I had one the other day that has been seen over 35 times in 2009 alone in our ED. When will it end??? We have to be part of the solution, and I do agree with the OP article.

I'm not doubting the woman in the article was in pain, but if she was evaluated (and I'm sure she probably was), there was nothing wrong with giving her a list of free-clinics or PMD's accepting new patients.

[Purple_Scrubs, BSN, RN]

When I first read this thread, I thought "good for that ED, get those people who do not need to be there OUT!" Now with some recent personal experiences, I have a different perspective...

I get kidney stones. I went to an ED with the first one, because even though I was pretty sure that is what it was, I needed the dx and I was in excruciating pain. Well, when I got the second one, I already knew what it was so I stayed home and managed my pain the best I could. Finally went to an urgent care when it did not pass on it's own. They only did a UA and said if it gets worse go to the ED :icon_roll. It did not pass in 5 days on its own, so I finally did end up in the ED to get a CT and see if it was too big to pass. It was not, and I actually passed it in the ED. Point: urgent care was virtually useless.

My husband was having severe stomach pains that came and went. I suspect gall stones, so we took him to his PCP. Took bloodwork (which takes 1-2 days to come back), and sent him for an US and CT (which could take up to a week to get scheduled and results read). Recommendation: if the pain gets any worse, go to the ED. Point: PCP is virtually useless. (BTW, we still don't know what is going on, waiting for US/CT results.)

So, I can see why people end up in the ED with serious but non-lifethreatening illness. I really wish I had taken DH to the ED, at least we would KNOW right now what he has going on. As it stands he has had this pain for 48 hours and we have no clue what is causing it. BTW, his PCP did not give him any pain meds or start antibiotics (pancreatitis is another concern). Like I said, useless.(We do have insurance and pay a $200 co-pay for ED treatment, then we still get bills for stuff that insurance does not cover. It is still better than waiting up to a week to get a condition diagnosed and treatment started. I don't want to wait until it IS a true life or death emergency!)

Next time when it is myself or my family, I will be one of those non-life threatening cases clogging up the ED.

[Katnip, RN]

You're confusing emergency and life-threatening.

Not all emergencies are life-threatening. Severe, sudden pain that doesn't go away with your usual at home treatment is considered an emergency. Kidney stones fit into that category. Sedond degree burns over a large portion of the body counts.

However, if someone has a chronic problem and just go to an ED repeatedly for meds rather than a PCP who can then send to a specialist to actually fix the problem, well that's not an emergency. It's a convenience for them. Often it has nothing to do with whether or not they have insurance.

Part of the problem is people don't want to bother making an appointment for follow-up because it takes too much time out of their day, or they don't want to think about it once the immediate pain/situation is taken care of-until the next time they get symptomatic and then it's off to the ED again for insta-relief.