Non-Emergent Care and Medicaid

People insured by Medicaid are quite likely to be drawn to emergency rooms by marketing campaigns such as HCA's "Moving at the Speed of Life" because they often do not have a primary care physician and fewer physicians are willing to accept them because of the low payments Medicaid makes for their care. The fact that they can receive care at a much lower cost to taxpayers in a retail or urgent care clinic is not a factor in their choice of where to go for care when they need it, and they are probably unaware of the relative costs of their care at these various locations. (See yesterday's post, Emergent and Non-Emergent Care: Definitions and Consequences.) Hospitals have no incentive to divert Medicaid patients because they receive a fee for every emergency department service provided. (Kaiser Health News and The Washington Post have collaborated on this subject as well.) Here is a key quote from South Carolina's Medicaid Director Anthony Keck: "Many hospitals are actively recruiting people to come to the ER for non-emergency room reasons. When you are advertising on billboards that your ER wait time is three minutes, you are not advertising to stroke and heart attack victims."

Medicaid is a joint federal-state program, and three states, Washington, Iowa, and Tennessee, have responded by limiting what Medicaid will pay for emergency room services. An especially inappropriate new practice is making the distinction between emergent and non-emergent care at the time of the final diagnosis. A Medicaid patient arriving with chest pain in my example yesterday may be required to pay the full price of emergency room care if the final diagnosis is heartburn instead of a heart attack. Similarly, neither the doctor nor the patient knows at first whether back pain is due to muscle spasms (non-emergent care) or a life-threatening aortic dissection (emergent care).

Emergent and Non-Emergent Care: Definitions and Consequences

Have you seen billboards advertising emergency room wait times? Where were they and what hospitals were named? The HCA North Texas hospitals have a website giving ER wait times. Are you aware of any other such sites? Do you have one of the smart phone apps that give ER wait times?

Marketing the convenience of emergency room care in this manner does not take into account the important distinction between emergent care and non-emergent care. I remember when people who qualified for emergent care and mothers in active labor were taken to the nearest private hospital emergency room and then re-routed to the nearest taxpayer-funded hospital. This practice resulted in the 1986 Emergency Medical Treatment and Active Labor Act requiring any hospital which receives Medicare or Medicaid payments (essentially all hospitals) to provide emergent care according to a legal definition. Defined for a layperson, emergent care is required in case of a immediate threat to a person's own life or someone else's life, a threat of grave disability, and active childbirth. If you arrive at the ER unconscious, bleeding, seizing, severely burned, with a suspected heart attack or stroke, broken bones, with difficulty breathing, or in active childbirth you will hopefully be well-treated. You will also be billed for the ER and hospital services, but whether or not you are insured, whether or not you are able to pay, is not supposed to influence the treatment you receive.

Non-emergent care is everything else. Defined for a layperson, it would be care that is required to avoid a crisis in the next 24 hours due to an unexpected illness or injury. For example, if you think you have flu symptoms and want a doctor's opinion and perhaps a prescription for Tamiflu to ameliorate the flu symptoms, that is non-emergent care and an emergency service is not required to treat you at all unless you are insured and can make your copayment, or can pay for all the services you receive out of your own pocket.

Returning to HCA's "Moving at the Speed of Life" marketing campaign, the distinction between emergent and non-emergent care will be made when you arrive at their emergency room. Kaiser Health News and The Washington Post collaborated in reporting that 314,000 people came to a HCA emergency room last year for non-emergent care. Of these 80,000 left without receiving care and 234,000 paid the $150 upfront fee required for treatment. That amounts to $35,100,000 and reduces the costs of care that is shifted to the hospital, the emergency physicians with whom the hospital contracts, and taxpayers. Other, smaller hospital chains are following HCA's lead, as are non-profits.

Americans often choose convenience over price, so there is every reason to think that some of these 234,000 people were happy to pay for it in this case. Many people who were unaware of the distinction between emergent and non-emergent care have now been educated or soon will be. No one knows what happened to the 80,000 people. Lower cost non-emergent care is available and might be just as convenient in retail clinic settings, as reported in this article from the Annals of Internal Medicine.

A reasonable concern is that emergency room prepayment will cause people to forego care. Undoubtedly that is what happened to some of the 80,000 people who left the HCA ERs without care. Some quotes from the KHN/WaPo collaboration give the physicians' point of view:

"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.

"After you've done the [federally required] medical screening, it makes little sense to not go ahead and write a patient a prescription," said Dr. Michael Zappa, a Boca Raton, Fla., hospital consultant and former president of the Florida College of Emergency Physicians.

The dangers of prepayment can be illustrated by considering a layperson, who cannot be reasonably expected to distinguish between the pain caused by heartburn and the chest pain that warns of a heart attack. If such a person decides not to make a trip to the emergency room, he or she may miss out on the significant benefits of early treatment to dissolve any blood clots in the heart's arteries, or of an angioplasty to widen an artery that has been narrowed by cholesterol deposits. There are many bad reasons for not obtaining an early diagnosis and treatment, but the barrier represented by prepayment should not be one of them.