What part of the word "emergency" do you not understand?

That’s a question many hospitals would like to ask patients who use the emergency room inappropriately.

And a growing number of hospitals are now giving such patients an ultimatum: If you come to the ER with a nonemergency, don’t expect to get treated unless you pay up front.

Piedmont Fayette Hospital, located in Fayetteville, south of Atlanta, adopted such a policy on Sept. 18.

"We’re following a national trend and trying to focus our limited resources back to emergency patients," said Ryan Duffy, spokeswoman for Piedmont Fayette.

Piedmont’s other two satellite hospitals, in Newnan and Jasper, also have implemented ER screening. The main Piedmont Hospital in Atlanta has not, though spokeswoman Diana Lewis said they are considering it.

Here’s how it works: Patients who come into the ER are evaluated by a physician. If their condition is a true emergency, federal law requires that they be treated, or at least stabilized so they can be transferred to another facility, regardless of their ability to pay.

"If the patient does not have an emergency, we recommend that they see a primary care doctor, and we give them a list of options in the community, including free or reduced-fee clinics," said Duffy. "If they insist on being treated in the ER, we will certainly do so, but they must pay either their insurance co-pay or a $150 deposit."

True emergencies include chest pain, trauma, severe bleeding, respiratory distress, stroke symptoms and other conditions that clearly require immediate attention.

"We are not turning anyone away," Duffy said. "All emergencies will be treated, and physicians will always err on the side of caution."

But they hope to discourage people from coming to the ER for illnesses such as colds, which could be treated in a primary care setting. In fact, some of the people who show up in the ER aren’t even sick at all.

"We’ve had people come in just trying to get a prescription refilled, and that is not what we’re here for," Duffy said.

Kevin Bloye, spokesman for the Georgia Hospital Association, said ER abuse is one of the toughest problems hospitals face.

"It’s an issue that every hospital in Georgia is grappling with," he said. "A lot of it is linked to the uninsured population, which is growing so fast."

If they are in danger of losing life or limb, uninsured patients can always get treatment at an emergency room. But Bloye said some people regard the ER as their answer for anything that’s bothering them.

"‘Frequent flyers’ are a huge problem," he said. "These are people who show up in the ER every week or every other week, often with behavioral or alcohol issues. They’re taking time away from other patients."

Cathy Bowers, spokeswoman for Northeast Georgia Medical Center, said the Gainesville hospital sees plenty of such patients.

"We have people who are habitual users of the ER," she said. "But treating patients who are inappropriate just encourages them to come back next time."

Bowers acknowledged that the medical center currently treats every patient who comes to the ER, even though federal law doesn’t require it.

"The regulations only say we have to triage and evaluate," she said. "But since patients incur most of their expenses during the evaluation, most hospitals just end up treating them."

Bowers said the medical center is considering adopting a policy similar to Piedmont Fayette’s, because it would put pressure on people to change their behavior.

The hospital has already tried a number of tactics to cut down on ER abuse. Though patients are not denied treatment even for minor conditions, when they’re discharged from the ER they are given a list of local, low-cost medical clinics and are encouraged to use those providers next time they need medical care.

The hospital also started Nurseline, a phone triage service. Patients can describe their symptoms to a nurse and determine whether they really need to come to the ER or not.

But it’s not clear whether these efforts are having an effect. Out of more than 97,000 visits to Northeast Georgia Medical Center’s emergency department in 2006, about 28 percent were considered non-emergent. And 41 percent of cases had to be written off as bad debt because patients didn’t pay the bills.

"The emergency room is the most expensive primary care you can get," Bowers said.

The cost of treating the uninsured has forced some hospitals nationwide to close their emergency departments. Yet there is still a reluctance at many hospitals to redirect patients who are inappropriate for the ER.

That reluctance is driven in part by fear of lawsuits. There’s always a chance that a doctor may send a patient home, only to have that person turn out to have a real emergency. But Bowers said more hospitals are now willing to take that chance.

"Liability concerns are one of the reasons the systems has evolved as it has," she said. "But everything in medicine has some risk of liability. You have to balance that against the risk of using your resources on non-emergent care and not having it for those patients who have true emergencies."