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Pay Up or Leave

Want non-emergency care in the emergency department? Pay up first.

After performing a federally-mandated screening exam, many hospitals are now charging an up-front fee of $100 to $150 to be treated for non-urgent complaints. Don’t want to pay? You’ll get a list of other health care resources and can leave.

And it is happeningalloverthecountry.

ACEP is against such a policy, arguing that 2 to 7 percent of patients determined to have “nonemergency” conditions are admitted to a hospital within 24 hours and that a vast majority of patients have conditions requiring urgent treatment.

I don’t think the policy is a bad idea, provided that patients have an alternative source for routine care. Medical care costs money … a lot of money.

The problem is that when the practice becomes commonplace and a public outcry occurs, I can only imagine what new laws that will be created to force hospitals/providers to provide treatment to all emergency department patients.


  1. The objections make sense: patients turned away for lack of funds will begin to distrust the hospital and believe that the staff is gaming them in order to avoid treating them. A better system would be NOT to close the doors on patients but to offer them an on-site alternative, i.e, the urgent care center or free clinic down the hall or across the street. In the Nashville story, 80,000 people declined care and no one knows what happened to them. That’s a deeply flawed approach on its face.

    • What’s deeply flawed about it? If they don’t have emergency care, why are they entitled to WC or any other physician’s services for free?

      How is it deeply flawed to say you have to pay for the labor of another?

      No one knows what happened to them? And? Are we supposed to track all people who ever show up in an emergency room?

      • What you’re saying boils down to a fundamental human rights question. How flawed is it to say you have to pay for labor of another? It must be presumed that the only reason a person is not acquiring care is because they can’t afford it! Should this person still be deprived of what we as Americans qualify as a human right? Unreciprocated labor MUST occur to make the world go round. In a field as selfless as medicine, humanity should play a core role. Is the system stable enough to support this today? Heck no. But it still is the right thing to do.

      • Yes, of course we should follow up on the 80,000 that may be turned away from ERs by such a policy. It’s deeply flawed because we have no idea whether the policy is effective or not. We’re guessing. You have left the decision regarding admission to an overworked staff under triage pressure. They have incentive to turn away the borderline cases so they can better treat the more seriously ill patients. Since there are zero consequences for erring on the side of non-admission, we should at the very least want to follow-up to ensure error (under-diagnosis) is minimal. This is especially true if it turns out some of those 80,000 mystery patients are simply showing up at the ER again two days later with a more serious condition.

        This is only a problem because of the SCARCITY of alternative urgent care and walk-in clinic services. It’s only reasonable to tell the patient to go somewhere else if the somewhere else exists. Most come to the ER because they believe it’s their only option for immediate attention.

        Plus, this system could definitely have the unintended consequence of providing patients’ incentive to up the ante on their symptoms: “They wanted to charge me when I had the flu, so next time I got sick I threw in chest pains too, and it was free.”

      • Where can I find the list of “human rights” in the Constitution that includes access to medical services for free? Now, if you want to say those are noble goals for medicine, sure. But to suggest they’re a “right”, which implies the force of law to provide them? No.

      • @Premedhead: That’s a lovely sentiment. Let’s see how it works out for you when you’re the one driven out of business because of it. “Unreciprocated labor MUST occur to make the world go round” sounds exactly like the argument the South made before the Civil War.

        I’m not a physician, I’m not in the medical industry at all. That doesn’t mean I have no dog in this fight — if I have an emergency I’d prefer the doc not be busy wasting time and money runny noses and pregnancy tests. Oh, and FYI — not all “we … Americans” qualify healthcare as a human right.

    • It doesn’t work. The hospital I work at has an after hours GP across the road. It costs $60, free for those on welfare…people would still rather sit in the emergency department.

      • The article says that only 5% of people are asked to pay and the elderly and children under 6 are exempt. That must mean that a significant % of drug seekers and chronic whatevers and whatnot are not asked to pay, and only the REALLY dumb stuff lands you a deposit.

        I can’t remember the last time I saw someone with a scratch or a runny nose or a dry cough for a day or two come back with something “serious” related to that complaint. Probably never.

        Unless you want the 8-24 hour waits that are common in urban-area ERs to continue, something has to be done, and I think this is more than fair. Obviously the worst-case scenario is that these hospitals that serve a largely uninsured and Medicaid population just go out of business…

        If you’re uninsured, you need to have some sort of action plan of what you are going to do if you get sick outside of hanging around the ER giving fake names or getting care they never expect to pay for.

        Human rights has nothing to do with writing scripts for Afrin or tessalon perles. The only legal requirement of an emergency room is that they provide a screening exam to see if there is a life or organ threatening injury or issue and stabilize the patient.

  2. People coming in to the ER with nonsense (had one yesterday that had literally a small scratch, someone else with a dry cough for a year, another with their 4th visit for a canker sore in a month) are a burden to the system and should be paying at least a $100 deposit. The deposit they’d pay at a charity or subsidized clinic is more like $20-$40 to be seen, and there are places to go that are truly free, such as resident clinics.

    I brought my son to the ER recently for a real emergency/injury requiring an urgent exam, and he was seen right away, but the doctor could have very well been tied up in a room with 6 family plan people with stuffy noses. $600 deposit for those stuffy noses and my son is seen faster.

    I could really care less if those stuffy nose people leave without prescriptions for Afrin when my kiddo is truly in need of help.

  3. Sounds good to me. I think I heard a ward clerk say about half the cases could be seen the next day when an immediate care facility is open.

  4. This is a good idea. Unfortunately people don’t realize that the E in ER or ED stands for emergency. I know of a family friend who went to his local ER for a boil to be lanced! As an allergist I frequently see patients who break out in hives and go to the ER. It is ludicrous how much nonsense is seen in the ER. Don’t even get me started about those without insurance….

  5. I might be in the minority, but I don’t agree that access to health care is a “Human Right”.

    I agree that a caring, compassionate people try to provide health care to everyone, but that is a Charitable Act. Not because it is a “Right”.

  6. I agree something has to be done to reduce the abuse of the ED with non emergent concerns. I’m not talking about the patients who use mdcd cards like an open ended credit card with no concern for payment. (Also – not all mdcd patients abuse the system and so I do not mean to infer that at all)

    But regarding the more responsible people …I can understand why a patient might present with a boil to be lanced or hives and some other things ..that could be taken care of in their pcp’s office, clinic, etc. When it’s after hours and the thing you’ve ignored is now very painful… or alarming for whatever reason. Sometimes ..well meaning patients hope things will go away because they DON’T want to be seen anywhere – denial)and then symptoms exacerbate off hrs. Hellooo local ED …

    I absolutely would’ve gone to the ED for hives at one time …before I knew better.

    January – 1985 …I came home from an extremely stressful situation …after 10pm, sobbing in my husbands arms and becoming progressively itchy. Looked in mirror and my face, upper torso – front and back covered in hives. (Never had hives before or since) SCARED the daylights out of me. I called the local ER. Thankfully, they still gave advice over the phone at that time. (The following yr I worked there (pt access) and they did not)the advice was to take Benadryl. It worked.

    There are times …people without medical expertise or personal experience will go to the ED for things staff knows could’ve waited to be seen by pcp, but they were genuinely concerned.

    If someone told me and I am guessing most reasonable people that their emergency was not an emergency, we’d be most happy to go back home and save some money. And many ins plans require a significant copay anyway. Also, the hospital I worked at also charged for triage if patient left without being seen. So would they charge a fee for triage? Or is that a free assessment?

    I think if you can work out the risk of missing a more serious case – it’s a good idea to reduce volume of unnecessary patients.

  7. I recently retired from a surgical specialty and have been doing ER medicine for the past 3 years in rural ER’s with a primarily indigent and medicaid/m’care population and I’ve been appalled at the massive abuse of the ER system by folks who are getting free care 24/7 as a convenience rather than a need. What to do? : require a “co-pay ” from all, even if it is $5-10. If they have no money, deduct it from their next government subsistance check. Many will say this is cruel, but if we would educate people in grade and high school health classes about common remidies for simple problems and teach them RESPONSIBILITY,then we will be able to save emergency care for those who truly need it. Health insurance carriers require a co-pay, why not the government insured who pay no premiums? The same goes for EMT and ambulance abuse. Many use it as a local free cab service. EMT’s should be better trained in acute diagnoses to better screen those with true emergencies and be allowed to refuse transport as indicated. A little austerity in this regard is an absolute necessity if we are going to deliver affordable emergency health care to those who really need it. With no disincentives for abuse, people will continue to take advantage of this EMTALA guaranteed “right” and bankrupt the system.

    • When people have a stake in their care, they might begin to show some prudence about where and when they seek help. And this goes for nearly every facet of our economic system, not just health.

      I probably have several issues that I should seek care for, but I cannot afford it and I know they won’t kill me. But these folks who are on permanent taxpayer support have no clue that they take from you and I. I absolutely agree that you need to force people to sit up and take notice until then, the insanity will continue.

  8. WC,

    Great article in today’s WSJ called “Why Doctors Die Differently”. You should definitely check it out.

  9. I think that people should be charged heavily for using the ER for non-urgent conditions. However, I think the flip side is that everyone needs insurance (and a provider or some alternative place to go)so when they are really sick, they don’t decide not to go because of the cash outlay. I guess theoretically this could at least partially occur in 2014. Once you have insurance and you go to the ER for bogus crap, you should be responsible for a large (or all) part of the cost of the visit.

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