Not Really An Emergency by Pat Conrad MD

It still surprises me when the lay public expresses shock at how much non-emergent, piddly BS shows up to the ER.  All of us in the ER wish we could make the casual, no-pay non-emergents (usually Medicaid) pony up at least $10 or $20 before demanding to be seen for a runny nose or menstrual cramps.

Maybe Blue Cross and Blue Shield of Georgia heard us, as it sent a letter to subscribers saying, “Save the ER for emergencies — or cover the cost… starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”  Because we know that Big Insurance is really concerned about ER overcrowding.

Of course they are not, but merely concerned with paying larger average charges for ER visits that could be more cheaply handled in private and urgent care clinics (I don’t blame them, but it’s not MY fault).  Anthem Blue Cross/Blue Shield has sent out similar letters in Missouri and Kentucky.  The president of the American College of Emergency Physicians says, “It is about the dollar. It is not about high quality care,” to which I reply, “Duh!”  Of course the ACEP prez is trying to keep her nest feathered by implying that ER care is ipso facto “high quality” (nice buzzword), and she knows very well that Big Insurance is trying to find ways to not pay for services already provided:  “For years, they have denied claims based on final diagnoses instead of symptoms,” and she counters with the “prudent layperson” standard, that would require insurance coverage be based on stated symptoms and not final diagnosis.

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A Yale health policy expert in the article says, “To me, this is a problem of the system.  This is not about bad actors.”  Well that’s obviously wrong, as it is also very much about lawyers forcing defensive medicine, sleazy Big Insurance and Medicare/’caid trying not to pay claims, and whiny patients and family members who run to the ER for the slightest discomfort and demand that everything be done.   It’s hard to blame the ER docs on this one when they are on-site, plenty busy, and not enticing patients inside.

Third-party payers trying to force patients to pay for non-emergencies will have some interesting side effects.  The biggest will be ER docs increasingly documenting such that an emergency condition appears in order to increase the likelihood of payment, sort of a fun variant of “up-coding”.  Oh, we won’t actually fake anything, but there is probably a way to justify labs and an abdominal CT for a diaper rash if we look hard enough.  While Medicare keeps trying to tie patient satisfaction scores to payment, expect those scores to drop and to be used in justifying penalties.   While new pressure will be brought against ER docs to lower the average number of emergent workups, expect the trial lawyers to exert counter-pressure to continue encouraging excessive and expensive workups; and they will be increasingly retained by patients with even minimal bad outcomes who have determined there was poor care …once they get the bill.

I’m too much of a cynic to really buy the ACEP prez worrying, “It’s really dangerous for our patients,” concerned that they will delay seeking care for fear of a bill.  That may deter a few, but the bulk of those affected will have non-emergency diagnoses after the big workup, pending reimbursement crank-downs.  No, this is all about Big Insurance trying to justify non-payment, and the targeted physicians who want to get paid trying to work up a good PR effort in defense.  This is how physicians have screwed it up for decades:  the AMA, AAFP, ACEP, et al come out wringing their hands over “our patients” when in truth they are primarily worried about getting correctly paid for good work they already did, and they ought to just say so.

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  6 comments for “Not Really An Emergency by Pat Conrad MD

  1. Peter Winston
    June 14, 2017 at 12:32 pm

    I’m all for patients having skin in the game, and the amount of skin should be tied to the type of insurance. A $50 or $100 copay for commercial is fine, but currently most Medicaid plans have ZERO copays for ER use. Medicaid copays don’t need to be much – $5 or $10 – to have an impact on utilization.

    And urgent care centers would be a much better resource allocation, even if it doesn’t result in more admissions to a hospital as would an ER.

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    • Pat
      June 14, 2017 at 1:52 pm

      Medicare should always have a co-pay as well. Lot of overutilizers there too.

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  2. Seneca
    June 11, 2017 at 10:00 am

    Unfortunately, these patients whose job it is to game the system will figure this out in a heartbeat. Just like the vets who know to say they are suicidal when they want three hots and a cot, the ER frequent fliers will learn to say they have chest pain. After all, who can say they don’t?

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  3. stevem64
    June 10, 2017 at 12:18 pm

    A couple of things:

    First, check out this article: https://www.washingtonpost.com/business/economy/free-standing-emergency-rooms-offer-costly-convenience/2017/05/07/6255d052-2b98-11e7-b605-33413c691853_story.html?utm_term=.970927be46b8

    Bottom line: When Emergency Rooms are placed in well insured neighborhoods, they are real profit centers. This is a problem for the system. Ads for these centers push their availability for back strain and other minor illnesses. So…. A $100 visit turns into $5000 and the hospital owner makes big bucks.

    A hospital can set up a freestanding ER within 30-35 miles from their facility as long as it can get the permit for the CT Scanner. It’s that easy.

    Our old vision of ER’s as money losing centers is outdated when you factor in these freestanding facilities.

    Second:
    What is an emergency?

    More than once this year, I’ve seen older patients discharged from the ER with “Pharyngitis.”

    The patient comes in a few days later.

    I look at them and ask: “What were you thinking, coming into the ER with such a problem? We could have seen you in the office within 24 hours!”

    The older patient says: “It was a funny upper chest pain radiating to my throat. I thought it might be my heart. I guess I just had strep.”

    With that kind of story in a phone call, we would have sent him to the ER, too.

    Third:
    Certain insurance companies are coming back to the Primary Care Physicians and asking: “Why did you send this patient to the ER for such a bogus problem?”

    Aside from the fact that our office was never in the loop, the patient thought he might be having a heart problem. Don’t we always say: “Dial 911?”

    The trivial diagnosis of “Pharyngitis” required an urgent exclusion of other life threatening problems.

    It WAS an Emergency.

    Fourth:
    Should the whole thing really cost $15,000?

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  4. Private Doc
    June 10, 2017 at 9:50 am

    You are right by law they must be seen. This is just a cost shift from the insurance to ER docs. If they can get away with this it will also start hitting the PCP offices, no culture proven bacteria? It was vital and could have been dealt with at home with OTC meds so no payment for the doc NOR the medication.

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  5. Steve O'
    June 10, 2017 at 9:41 am

    Fifty years of finagling, spot-welding and temporary fixes has produced this ridiculously unstable Jenga Tower of a “healthcare system.” It has been designed and built by idiots with no clue as to the nature of medical care, based on assumptions that everyone, even the idiots, can tell are frank lies. Academia has grown fat on lying for profit about how to improve healthcare; politicians have run with it, and insurance companies have gotten fat from it.

    DId you know that the “Healthcare” sector on Wall Street/NYSE has BEEN IN THE BLACK every year since 1980? It’s a no-lose gamble! You’d expect that if, say, the Automotive Sector was in the black EVERY YEAR since 1980, we’d be folding up our flying cars like George Jetson. Look at what a miracle healthcare is today!

    And everyone is hovering around the rickety tower and asking – which block needs to be pulled out, to stabilize the damn thing? It doesn’t work like that, folks.

    It’s too late to stuff enough of an add-on support structure, a Bledsoe-for-Healthcare, to prevent it from collapsing. But that’s true in a lot of other places in American society; that’s why we’re in our twilight.

    The ER is a symptom of major collapse. I cannot admit sick people to the hospital. They go to the ER, get sent home and die from cardiac dyspepsia. Who knew? And yet the bureaucracy staffed with people-looking-like-they-do-something doubles. We should just change the name of “Healthcare” to “Employment.” It makes jobs! That’s mostly what it does.

    Pull out a block. Go ahead, any one. It doesn’t matter.

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