• 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.

    • 80,000 ER patients / 163 facilities (excluding surgery centers) = 491 / 365 days per year = 1.3 people per facility per day that were told to pay first.

      Explicitly might be a tad strong.

    • Whether 2 per day per facility or 20 the point is still the same. The overall perception of the US public is that the ER represents a part of the “safety net”. What this tells us is that those who cannot pay are denied care. While not life-saving, the care denied is in at least some instances necessary.
      What we do know is that in 2012 patients without the means to pay for care have the right not to die in the ER. Some solace.

      • Spare us the fear-mongering. The post clearly says this practice was for people who were going to the ER for routine care, not an emergency. People weren’t “dying in the ER” because of this.

        • Routine care? From the article.

          “”This is a real problem,” said Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours.”

          The agency with a financial interest is deciding what is and is not urgent. This would be the same HCA which requires its docs to push treatments that make more money for the hospital. The name Rick Scott seem familiar?


          • 2 to 7 percent sounds like about what I’d expect for the “failure rate” of an ER to figure out whether someone has a serious problem. ER docs are no more perfect than any others, and it’s often busy and fast-paced. Are you suggesting those doctors are intentionally turning away patients that they know have a serious problem?

            • @AB-I checked with my friend who consults for ERs. He tracks about 200 in his database. Their admission rate at 72 hours, not 24, is 1%. 2%-7% at 24 hours is very high. As to motive, I suspect these patients never make it so far as to see a doc.


    • I think the numbers matter a bit. It’s clearly not true that everyone has access to care via the ER, but if if 90-95% of the cases that prevent get screened and treated it is pretty close to true. That doesn’t make it a good idea or a substitute for an actual system.

    • Not that a UK-like system would be an improvement:



      Waiting-list clerks are at the sharp end where the cash crunch meets the impossible target – and here’s what Carol says she was ordered to do:

      She was told to cancel operations for anyone who was already waiting over 18 weeks, and instead to fill that theatre time with people closest to breaching the 18-week limit. “I was told to call people who had already gone over the 18 weeks and pretend there was no longer theatre time for their operation, and not give them a new date.” She was told not to book anyone already in breach until April and the start of the next financial year, or to book only one for every nine still under the target. Instead she was told to fill theatre slots with as many short, minor operations as possible.

      Next she was told to use devious means for knocking people off the waiting list. The worst was when she was told to call a mother of three young children to offer her a short-notice slot for Christmas Eve, knowing she would refuse and so could be knocked off the list for refusing. “We would offer operations at very short notice to people getting near the 18-week deadline. You hope they’d say no so you count them as a refusal and knock them off.”

      She protested first to her line manager, then to the one above and finally to the one above that. “I said I wanted these instructions in writing before I would lie to patients. Of course they said it could never be written down. But the manager in charge of operating theatres said other hospitals were all doing it, so we had to too. There’s no other way to stay within target.”

    • I realize that it wasn’t the point of the post, but I’d be curious to hear how ACA fans would respond if this kind of measure if it were mandated under the ACA.

      Screening patients and shifting non-emergent cases away from the most costly setting to something closer to a primary care clinic, coupled with financial incentives to nudge patients towards the most appropriate care setting…what’s not to like? Seems like something that would be universally applauded under a single-payer regime.

      My sense is that the same folks that view this sort of cost-control measure as sinister when driven by health insurers, tend to applaud them when they’re imposed by government. To be fair, the converse is also true.

    • There is a problem with people going to the ED for non-emergency illness. The ED is a critical care area. Meaning high cost to keep staffed, high cost equipment, etc. But, no where else to go if you can’t pay or have no insurance. But, even those on the state of Oregon Health Plan, where I live cannot get in to see their assigned doctor or licensed practitioner because those offices are all booked up. Even with insurance,trying to get in to see your doctor can take days if not weeks. And the “Immediate Care” clinics demand money up front. I have thought that a single payer system would be the answer. It would do thecsts of the billing department that trys to pry money out of the various insurance schemes whose sole purpose is to make money for the shareholders at the expense of the stakeholders. But that is only part of the problem. State sponsered insurance for the poor actually does an admirable job at trying to hold down costs by restricting what they pay for the various procedures and office calls, but the problem is that the medical doctors don’t want to take up their office space with those who will compensate them less for the same service. Besides they are full already. Those MDs that can take the public patients are almost inevitably those MDs that do not have hospital priviledges. Meaning they cannot take care of those pt.s after they are admitted to a hospital with a serious illness. Some hospitals have Dr.s that work in the hospital to take care of these pt.s but sadly these tend to be MD.s that for one reason or another do not have a practice of their own. Often moving from contract to contract and hospital to hospital. Not all MD.s are created equal.
      Additionally, there is a political bias that some doctors have against those on public insurance. It is that “we are paying for YOUR care” attitude. And I can state with certainty that that leads to ER pt.s getting discharged home who would otherwise have been admitted for their illness. People die from this.
      Solution: A single payer, taxpayer supported system. All citizens contribute something. Rich more than the poor. Only fair.
      Treatment protocols and payment is set by state boards answerable to state congress using professional input.
      And to get more providers. Highly subsidized schooling for Primary Nurse Practitioners and Physicians Assistants.
      If everyone had the same ability to pay there would be no need for difficult billing processes. Low overhead, reduce costs,and provider offices would spring up. The only thing holding FNP’s and PA’s back is the overhead and red tape. And think of the benefit if doctors offices were open 24 hours a day, staffedby these other providers. Same office, same building in use all day instead of just 8 hours.
      Yours truly,
      Greg H
      ED RN