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So Much For “Everyone Can Get Care In An Emergency Room”

We’ve long argued this meme isn’t true. But now it’s explicitly false:

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation’s largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Led by the Nashville-based HCA, a growing number of hospitals have implemented the pay-first policy in an effort to divert patients with routine illnesses from the ER after they undergo a federally required screening. At least half of all hospitals nationwide now charge upfront ER fees, said Rick Gundling, vice president of the Healthcare Financial Management Association, which represents health-care finance executives.

So sure you can get non-emergent care in an ED – if you pay for it out of pocket. Please understand I’m not saying that all care should be free. I’m saying that the emergency department is no different than a physician’s office. If you have insurance, or can pay for care yourself, you get it. Otherwise, you don’t. No matter where you are.

Why is this happening?

Hospital officials say the upfront payments are a response to mounting bad debt caused by the surge in uninsured and underinsured patients and to reduced reimbursements by some private and government insurers for patients who use the ER for routine care.

And what about prescriptions?

In December, Skaggs Regional Medical Center in Branson, Mo., began asking ER patients to pay $40 or their insurance co-payment before receiving a prescription.

“If they don’t pay . . . they won’t be given their prescription,” hospital spokeswoman Michelle Leroux said.

The strategy is designed to help the hospital deal with spiraling, unpaid ER bills. About a third of the 120 patients treated daily in the hospital’s ER are uninsured. The change was implemented after the ER reported $1.3 million in bad debt for August.

So please, don’t keep arguing that everyone has access to health care because they can just go to the emergency room.

Aaron E. Carroll, MD, MS is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine, as well as the director of the Center for Health Policy and Professionalism Research. Carroll’s work has been featured in The New York Times, USA Today, The Los Angeles Times, Newsweek, and many other national publications. He blogs at The Incidental Economist, where this post was originally published.

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4 replies »

  1. What is the purpose of and EMR (electronic medical record)? It allow easy tracking of patient outcomes by the Government, Insurance companies and other institutions including the doctor.

    What helps an EMR be a good one? It is important for the EMR to be user friendly and provide safety in use. A good EMR is easy to use especially when documenting values that are normal, and help offset extra time by creating shortcuts for these normal values. Default usual dosing of medication is important to help the doctor avoid prescribing too little or too much, and will point out interactions of drugs to the doctor to help make the doctor aware of alternative medications.The system should be up to date, respond quickly and integrate with other parts of the system such as Radiology imaging, signing records, and checking lab values from prior visits, and integrate with other EMR systems from physicians offices,especially those systems that the hospital set up for the doctors offices.

    Why is this important to the patient? Doctors that spend too much time finding and documenting this information can compromise the time spend taking care of the patient. A good system should be instituted in a phased in manner to allow the physicians and support personnel to become comfortable with the system. Those doctors who cannot adapt need to be given extra support by the Hospital or in the Outpatient setting to offset these problems. It is the Hospital systems responsibility to provide the best system possible and the greatest support possible to assure good patient care by the personnel that use it.

    What are the deficiencies of HCA with their current EMR? Their EMR is ancient dating back prior to 1985 and sorely requiring revisions that the administration is unwilling to provide. Although it is a temporary system, it is expected to be in place for 5 years. The language is as old as DOS and is pieced together as 5 parts that communicate slowly. The Radiology, Permanent EMR record, financial systems, EMR writer, and laboratory values are all separate systems that make for slow response.

    To add to the problem is an administration in Tennessee that only thinks in dollars and cents. They find it too costly to invest in this “temporary” system with the integration of physicians and IT personnel to make it work better. No default values for usual medication dosing. Difficulty in reviewing old medical consultations, lab values, and radiology. Poor template default values for normal exams, and poor ability to communicate information in the physician notes to other doctors. IT personnel are slow to institute change and many changes appear to be without physician input. The outpatient EMR system that they have supported for their doctors does not integrate with their EMR system.

    Word to characterize their system: Cheap Inefficient, Outdated, Slow, Poor integration, and Poor support. This combination makes it unsafe for patient care regardless of the quality of the physicians using it.

  2. Some of the lack of emphasis on primary care may be coming back to bite us!! Most of all this supports the fact that we do not have a health care system and when someone who speaks from experience and reason like Don Berwick he is shouted down and ushered off the stage.

  3. Sounds like a dream come true. ERs should be divided into the EMTALA ZONE, the EMERGENCY ROOM, and the Cash & Carry clinic.

    Everyone gets the mandates screaming exam for medical stability. That is “free”. If you are”Medically Stable”, then the free stuff is over.

    What is wrong with that?

    Co-pays can only be required after a medical screening exam finds the patient is stable.

    So, yes,everyone has access to needed care. NOT unnecessary care, like most pediatrics.

  4. We are in an untenable situation – ERs cannot continue to provide free care for patients who do not have an emergency. There are only so many resources; diverting them away from heart attack and acute appendicitis patients for ear aches and dental pain, along with medication refills – all things that can be taken care of by a primary care doctor as a non-emergency – is not only appropriate but necessary for the continued functioning of our current system and our promise (and federal law) that medical care FOR EMERGENCIES will continue to be provided in our emergency departments.

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