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Looking elsewhere for care: ER payment plan seeks to redirect nonemergency cases

POSTED: June 4, 2008 5:02 a.m.

Donna Hughes, a licensed practical nurse, right, takes Romain Chateauvieux's blood pressure Friday afternoon at Quick Care in Sherwood Plaza upon Chateauvieux's arrival. The Northeast Georgia Medical Center will require patients to pay up front if they come to the ER for treatment of a nonemergency condition.

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If Northeast Georgia Medical Center’s new payment policy works as planned, it could have a ripple effect on the rest of the local health care community.

As of June 1, patients who come to the emergency room without a serious or life-threatening condition will be asked to pay up front for their care.

Uninsured patients will be charged $150; insured patients must pay the emergency room co-payment specified in their health plan. People who do not want to pay these charges can seek treatment at a primary care facility, which is exactly what hospital officials are hoping that they’ll do.

"We exist for emergencies," said Jim Gardner, president of Northeast Georgia Health System.

For many years, the hospital has struggled with how to deal with people who come to the ER for routine health care. These patients are known as "nonemergent," and they account for fully one-third of the 100,000 patients treated in Northeast Georgia Medical Center’s emergency department each year.

Gardner said patient volume has grown so much that the ER needs to devote its resources to treating heart attacks, trauma victims and other serious cases, not earaches and sore throats.

"When you’re as large as we are, it gains a certain critical mass, and we’ve reached that point," he said.

The problem is, there’s a federal law that requires hospitals to treat anyone who comes in with a true emergency, no questions asked. Each patient must be evaluated to determine the severity of their condition.

Technically, hospitals are not obligated to treat once the patient has been diagnosed with a nonemergent condition. But in the past, most ERs treated patients anyway, since they had already been through the intake and examination process.

Those days are gone. Many hospitals, in metro Atlanta and nationwide, have already implemented an advance payment policy for the ER.

"We’re actually very late to this game," Gardner said. "Up to now, we’ve been hesitant to request payment up front."

But what happens is that people who don’t pay up front often don’t pay at all. The hospital has to bill them repeatedly, turn them over to a collection agency, and eventually write it off as bad debt.

Though the $150 fee may come as a shock to some patients, it’s only a fraction of the $1,000 or more that an average ER visit actually costs.

"In the scheme of what it costs to run an ER, it’s a nominal amount of money," Gardner said.

He emphasizes that not everyone will have to pay that much.

"All patients, elective and nonemergent, are eligible for the hospital’s very generous charity discount (based on income and federal poverty guidelines)," he said. "Part of our mission is to provide care for people who don’t have the means."

The medical center has already revised its payment policy for elective procedures, such as CT scans, MRIs and minor surgeries. Before undergoing the procedure, uninsured patients must pay 25 percent of their total expected cost, or $500, whichever is less. They’re also asked to sign a promissory note for the balance.

Gardner said the policy has worked fairly well since it was implemented in April.

"We’ve had to reschedule maybe 20 patients because they didn’t have the money at the time, and 90 percent of those were rescheduled fairly quickly," he said.

As for the ER, Gardner wants to make it clear that no patient who has a true emergency will ever be denied treatment.

"One hundred percent of patients receive a thorough screening," he said. "We rely on the physician’s judgment to determine whether the patient is emergent. It’s not based on ability to pay."

And people can still get treated in the ER for minor ailments, as long as they’re willing to pay the fee.

But they will also be offered a list of other, much less expensive treatment options. Patients who can’t get in to see their regular doctor, or who don’t have one, can go to a walk-in clinic such as Northeast Georgia Health System’s Quick Care.

Low-income or uninsured patients may be referred to Good News Clinics, Medlink Gainesville, or the Hall County Health Department.

The hospital has been trying to educate patients about their primary care options, but so far only at the point when they’ve already been treated in the ER.

"(That approach) wasn’t working," Gardner said.

Health system spokeswoman Cathy Bowers said Quick Care received 15,708 visits from October 2007 through April 2008, compared to 14,769 during the same time period a year earlier. But the increase in patient volume at Quick Care was not matched by a corresponding drop in ER visits.

Gardner said the health system is not changing its ER policy in order to be punitive.

"It’s about making sure the health care dollars in our community are spent as wisely as they can be," he said. "The ER is four to five times more expensive than going to a walk-in urgent care (clinic) or your personal doctor’s office. We’re trying to encourage a change in behavior."

That change may come slowly. At Piedmont Fayette Hospital in Fayetteville, which adopted a similar ER policy last fall, spokeswoman Ryan Duffy said they’ve yet to see a big drop in ER visits.

"But the referral list has been a great tool for our community physicians," she said. "Sometimes patients are new to town or visiting from out of town, and they go to the ER because they don’t know where else to go."

Duffy said many of these patients are grateful to be given a list of alternatives. But there has been griping from patients who habitually go to the ER in search of free care.

"We’ve had some challenges," Duffy said. "You’re never going to make everyone happy."

If the policy works in Gainesville, it could mean more business for local clinics and doctor’s offices. Patients who have insurance or who can afford to pay the full cost should have no trouble finding primary care. For low-income patients, however, the options are somewhat limited.

The Hall County Health Department charges uninsured patients on a sliding scale based on income. But its primary care clinic, which has one full-time and one part-time physician and one nurse practitioner, is not equipped to handle a huge influx of new patients.

"We do see referrals from the ER for people who do not have a medical home," said nurse manager Alan Satterfield. "It probably takes about two weeks to get a scheduled appointment. But we’re able to take walk-ins, depending on appointment volume. If we have a lot of no-show patients, we can take more walk-ins."

Patients at the extreme low end of the income scale can get free medical and dental care at Good News Clinics, where director Cheryl Christian said she expects to see an increase in patients as a result of the hospital’s new policy.

"We anticipated this happening and have tried to plan for this," she said. "We have some slots saved for walk-ins."

Christian said the nonprofit clinic, which is funded through donations, has received a two-year, $150,000 grant from the Health Care Georgia Foundation that will allow Good News to hire another nurse practitioner.

She added that the clinic has already been trying to educate patients about proper use of the ER.

"We encourage them to call us if they have a sore throat rather than going to the hospital," she said.

Christian believes the medical center’s payment policy will help people make better decisions.

"I think some people truly don’t know they have other options (for health care)," she said. "But I think others just go to the ER out of habit. Appropriate use of the ER will benefit all of our community."


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