How Ideas to Cut ER Expenses Could Backfire

[bebbercorn]

How Ideas To Cut ER Expenses Could Backfire

by Nancy Shute

March 20, 2013

Cash-strapped states are coming up with an appealingly simple fix for soaring Medicaid costs: Don't pay for emergency room visits for people who aren't sick enough to be there.

There's a problem, though. It's almost impossible to figure out who's sick enough and who isn't at the moment they walk in the door, researchers say.

"People don't come to the ER with diagnoses, they come to the ER with symptoms," says Maria Raven, an assistant professor of emergency medicine at the University of California, San Francisco. She's the lead author of the study published in the latest JAMA, the Journal of the American Medical Association.

Almost a dozen states have come up with plans to refuse to pay for ER visits or require copays from Medicaid patients if they have a health problem that could have been treated in a doctor's office. They're operating on the widely held premise that people without private health insurance use emergency rooms for minor complaints that would best be treated elsewhere.

To find out if that's true, Raven and colleagues looked at the discharge records for almost 35,000 people who visited emergency rooms in 2009. They identified which people had problems that were "primary care treatable," and then looked back to see what symptoms brought them to the ER.

Just 6 percent of the people had a problem that could have been treated in a doctor's office. But it was impossible to identify them based on symptoms when they walked in the door, because they were the same as those for 89 percent of all emergency room visits. The hundreds of symptoms included toothache, skin rash, abdominal pain, earache, fever and chest pain.

Looking at the people with those symptoms, 11 percent were triaged as needing immediate care, and 12 percent were admitted to the hospital. The three most common diagnoses were abdominal pain, respiratory infection and chest pain....

[bebbercorn]

Should we be getting ready for pay cuts?

[tewdles, RN]

This is a REALLY bad idea.

Perhaps they should cut reimbursement to PCPs whose answering machine sends all patients to the ED after 4pm M-F

[Roseyposey]

I absolutely agree that the patient does not go to the ER with the diagnosis, so let me get that out there. We are all taught that chest pain is serious until all red flags are ruled out. period.

That being said, the #1 unnecessary ER complaint paid with Medicaid funds in my state....drumroll please: URI. This is a patient education problem. Some hospitals are responding to ER clogging by opening urgent cares, which my hospital recently did. The problem, IMHO, is the logistics - they opened it six blocks away. I am certainly not as smart as the powers that be; however, "if I ran the world...." I would open it within spitting distance of the ER.

[psu_213, BSN, RN]

Some hospitals are responding to ER clogging by opening urgent cares, which my hospital recently did. The problem, IMHO, is the logistics - they opened it six blocks away.

The other issue is that ambulances don't "deliver" to urgent cares.

Here's the issue with copays for medicaid pts. Let's say they just want the copay to be a "deterrent" to keep away the most silly of ER visits (such as CCs of "toothache," "finger pain for 3 months," or "can't get an erection"--yes, I have seen the last CC). Since these individuals have little money we make the copay $5. Well, what if they don't have the money with them? They still have to be evaluated by a doctor per EMTALA...the would still need a screening exam. They don't pay the copay at the time, so the hospital bills them for it. How many other unpaid bills do they have? Is a $5 bill really going to faze them? They already have a credit score of 3...what is the big deal if they have one more bill sent to collections? Then all it will take is one person who didn't go the ER with a serious complaint because they were "afraid" of the copay...they have a poor outcome...then certain people are up in arms because we've created a system that further disadvantages people of a given socioeconomic status.

[Not_A_Hat_Person, RN]

Perhaps they should cut reimbursement to PCPs whose answering machine sends all patients to the ED after 4pm M-F

Better yet, cut reimbursement to PCPs who send all patients with the slightest hint of illness to the ER, even during office hours. When I was an ER volunteer, on weekday afternoons, a lot of people came in for X-rays, MRIs, CT scans, suture removal, and other minor problems because "My doctor told me to come to the ER."

The last 3 times my husband went to Urgent Care, they sent him to the ER. He was treated and released 2 times, and admitted the 3rd time. Would any of those visits be considered unnecessary? After all, Urgent Care told us to go to the ER.

And why only Medicaid? A growing number of PCPs are refusing to take Medicare patients; why not refuse to pay for unnecessary Medicare ER visits?

[psu_213, BSN, RN]

Better yet, cut reimbursement to PCPs who send all patients with the slightest hint of illness to the ER, even during office hours. When I was an ER volunteer, on weekday afternoons, a lot of people came in for X-rays, MRIs, CT scans, suture removal, and other minor problems because "My doctor told me to come to the ER."

I always like when someone signs in with CC "doctor told me to come in." I always say to myself 'just write why your doc wanted you to come in': "abd pain", "calf red and swollen", etc (those could be real reasons for a pt to come to the ED). With some of the reasons for which PCPs send in pts--well, my real complaint would also be that my PCP told me to come in rather than deal with it in the office.

[bebbercorn]

I just can't understand why we can't get this fixed... genuine complaints or rule outs by all means I understand. But the fact that I have no where else to go but an ED for any care after hours just makes no sense. These pay cuts are going to affect docs, nurses and ancillary staff, not the bigwigs at the top. What about bringing back house calls?

[SuzieVN]

Should we be getting ready for pay cuts?

The cuts began 5, 10 years ago.

[SuzieVN]

I've always told family/friends, that 'really'- if you 'must' (and I am talking 'bona fide' stuff) go to an ED? Then tell them you are having chest pains when you walk in. That way you bypass the velvet rope. When the doc comes in, tell her you had an anxiety attack, is all- that the real reason you came is because of an open fracture in your ankle...and look- there's the bone!

Sorry to let the world know, ED nurses, a way to avoid the masses that do go to the ED for hangnails, split ends, and the like- but some people really do have emergency situations when the enter an ED.

[salvadordolly]

A hospital in my area began charging $100 cash for any complaint not triaged as emergent. I worked at the other hospital, where the patient would come instead. They closed my hospital to prevent the losses. Meanwhile, no urgent care within a 10 mile radius. What the hell were these people supposed to do?

[LadyFree28, BSN, LPN, RN]

Better yet, cut reimbursement to PCPs who send all patients with the slightest hint of illness to the ER, even during office hours. When I was an ER volunteer, on weekday afternoons, a lot of people came in for X-rays, MRIs, CT scans, suture removal, and other minor problems because "My doctor told me to come to the ER."

The last 3 times my husband went to Urgent Care, they sent him to the ER. He was treated and released 2 times, and admitted the 3rd time. Would any of those visits be considered unnecessary? After all, Urgent Care told us to go to the ER.

And why only Medicaid? A growing number of PCPs are refusing to take Medicare patients; why not refuse to pay for unnecessary Medicare ER visits?

^I was explaining that my state has done this on another post...a lot of people on Medicaid in my state CAN NOT or lost the privilege to see a PCP, especially with a particular insurance company, and received a letter about being responsible for the bill if it is non emergent...they are at the mercy of a health center overcrowded with people who do not have insurance, that is only open 9-5 with the possibility of not being seen or treated in urban areas. or no access to healthcare if they are in rural areas...

In my state, I have not heard about PCPs turning away Medicare pts but they have been turning away Medicare pts for at least 5 years.

Another reason why most PCPs are sending pts to the ED is that the ratio of PCPs to pt load is close to critical. I remember my physical, she was seeing two other pts simultaneously...one was across the hall, and the other one was next door.

This is NOT good either way...the system is about to IMPLODE!!!