Upfront payment for non emergent conditions

Specialties Emergency

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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.

Specializes in ED.

This is such a touchy subject. All you need is to miss one pt that goes off to an urgent care clinic and croaks on the way. I work in a southern Florida ED, and a lot of the stuff we see should be handled by a PCP. The problem is, most GP and PCP have left this area of work to head to specialities or hospitalist positions, leaving very few PCP's in the area. I had no problem sitting at the health dept for a few hours, but most people are impatient. They are looking for the McDonald's version of healthcare- cheap, fast, and instantly gratifying.

To combat our insanely high pt count throughout the day, our ED medical director sat down and reorganized the schedule, and added a 'PA/NP' position to handle fast-track and RME pts. The response has been wonderful. Pts are happier, LOS is down, and complaints have dwindled. Can't remember the last time I had to fill out a risk master based upon pts LOS and the attitude that followed. This effort was taken after our 15 bed ED was renovated into a 32 bed ED, with no increase in staffing. Sure, we used to run with 30 pts, all in hallway beds, and the promise has been made of no more hallway beds due to the new advert of 'all-private rooms', and so far it has been kept.

People are going to have unrealistic expectations. I, just like many of you, hate to see the 23 year old come in for N/V x2 hours by EMS because it is a waste of resources. I truly think some pts should get an Elmo band-aid and a 'kiss' to make it better.

I always tell my pts who come in by EMS for some trivial, random nonsense (cold s/s, the 30 yr old with constipation, the toothache) that "there are 8 ambulances for 40,000 people in this town, QUIT USING ALL THE AMBULANCES!"

I just don't understand why you couldn't have your mother bring you up, who followed EMS from home and could have driven you too, but you sit down and watch too much 'House' or 'Trauma: Life in the ED" or are on WebMD before deciding to call EMS, and you think your benign s/s could be the next rare, misdiagnosed disease. If I had a nickel for everytime I heard "well I read on WebMD...." I would be very well off.

There are many problems with the current state of our ED's. Maybe the definition of 'emergency' should be placed next to the ER sign. I have often wondered why not set up a clinic on campus, and refer the level 5 to the clinic?

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The hospital I work at already has this practice in place. When we first started doing it, it worked out pretty well. Of course, we had some patients that didn't believe we could do it and threatend to sue us, because their spouse was a lawyer. Sure! And some patients were fine with it. Our Docs are the ones doing the medical screening exam and if they decide it is not an emergency they usually tell them right away what is happening before the patient is sent to registration and they are told they will need to pay before any other service is given.

This practice has since died off. Not many of our docs are doing the screening exams anymore and I'm not sure why. I've heard it is fear of lawsuits. Hopefully is stays in place longer in your ED.

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I'm sure it's a liability issue. I'm sure we've all been in situations where our instincts were a little off and as things progressed, we realized it was something else.

Health and personal care ignorance is huge. Someone could come in for a broken nail. Check their history ect everything looks good. Then you start running tests and find bp 200/110, glucose spilling into their urine, ect ect.

Happens all the time. I find it's usually the ones with the vague complaints end up being the surprise. Can you imagine what would happen if someone left ER cuz they were expected to pay up front and then something happened? Lawyer lawyer.

I saw something last night that reminded me again why there is no answer for this problem. Someone on a transplant list who didn't want to pay the copay or the hospital bill.. Who was ill but not 'that' sick but based on the organ that he's waiting on was a super huge deal. The ones who REALLY need the help will not get it because they see the money owed as more serious than the possibility of death.

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Specializes in Emergency & Trauma/Adult ICU.
I'm sure it's a liability issue. I'm sure we've all been in situations where our instincts were a little off and as things progressed, we realized it was something else.

Health and personal care ignorance is huge. Someone could come in for a broken nail. Check their history ect everything looks good. Then you start running tests and find bp 200/110, glucose spilling into their urine, ect ect.

Let's not make things sound unnecessarily scary. The MSE is not simply noting the stated chief complaint -- it includes a basic history and vitals. The SBP > 200 would be the end of consideration of the patient being discharged without being evaluated by a physician. With more normal vitals, there is no reason to check a urine specimen on a patient with a broken nail.

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I think this is a great idea. I don't see how asking for payment upfront for non life threatening events is going to be cause for a law suit. No one sues the primary care office or urgent care when they require payment upfront and DON'T do any type of MSE. People need to take responsibility for themselves!

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Specializes in ER, Med-surg.

We do it at our hospital. I think it's great- the providers don't love it (since they have to do the screening but don't get reimbursed) but it saves a ton of nursing time (and aside from saving our sanity, hey- we're a valuable resource which should be available to give quality care to the truly emergent, not filling out busywork for those who aren't) and it also means those people stop considering the ED "easier" than the clinic for things that are nonemergent.

The criteria for who can and can't be Q'd are clear and strict, and PLENTY of stuff that turns out to be nonemergent still makes it back because their presentation isn't cut and dried and triage always errs way far on the side of caution (and plenty of people who are Q'd by triage get un-Q'd by the provider when their assessment reveals something concerning). But if it's something where the focused assessment, history, and vitals reveal nothing emergent, and the providers (who STILL SEES THE PATIENT and signs off on the decision, remember) agrees, then saying that not giving them a full workup for free is somehow wrong or a liability is just goofy. ERs are required to provide assessment to all comers and stabilization for EMERGENT conditions, not all medical care with no upfront costs to anyone who can get themselves there.

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I work in an emergency department that requirs uninsured pts with non-emergency complaimts pay $250 toward their bill ig they want care or prescription treatment. Most people leave and we refer them to free clinics.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
I work in an emergency department that requirs uninsured pts with non-emergency complaimts pay $250 toward their bill ig they want care or prescription treatment. Most people leave and we refer them to free clinics.

Interesting. Are they getting an MSE as part of triage to determine that their complaints aren't emergent?

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Let's not make things sound unnecessarily scary. The MSE is not simply noting the stated chief complaint -- it includes a basic history and vitals. The SBP > 200 would be the end of consideration of the patient being discharged without being evaluated by a physician. With more normal vitals, there is no reason to check a urine specimen on a patient with a broken nail.

EXACTLY...

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We do it at our hospital. I think it's great- the providers don't love it (since they have to do the screening but don't get reimbursed) but it saves a ton of nursing time (and aside from saving our sanity, hey- we're a valuable resource which should be available to give quality care to the truly emergent, not filling out busywork for those who aren't) and it also means those people stop considering the ED "easier" than the clinic for things that are nonemergent.

The criteria for who can and can't be Q'd are clear and strict, and PLENTY of stuff that turns out to be nonemergent still makes it back because their presentation isn't cut and dried and triage always errs way far on the side of caution (and plenty of people who are Q'd by triage get un-Q'd by the provider when their assessment reveals something concerning). But if it's something where the focused assessment, history, and vitals reveal nothing emergent, and the providers (who STILL SEES THE PATIENT and signs off on the decision, remember) agrees, then saying that not giving them a full workup for free is somehow wrong or a liability is just goofy. ERs are required to provide assessment to all comers and stabilization for EMERGENT conditions, not all medical care with no upfront costs to anyone who can get themselves there.

Ugh... So unbelievably right on the money, no pun intended... Have a guy who has been through almost all of the ERs in Baltimore here getting free dialysis whenever he wants... This guy has no means of payment whatsoever, refuses to get labs drawn, and refuses time and time again to follow-up with our social workers to work on applying for medical assistance programs and refuses to go to scheduled outpatient facilities for dialysis... He is never in acute distress and he is ALWAYS stable, and yet, we admit him and attempt to work him up, taking up a valuable bed... Every other hospital now refuses to treat him except us, people like this absolutely strain my workflow and it is nearly one-third of the people that come in... We have resources for them, but end up caving and admitting them for non-emergent treatment and obs

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Specializes in ER, ICU.

MSE's have been done by many ED's in my area for several years now; hospitals are trying to find a way to stay in business and this is an effective tool.

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