Emergency. Dictionary.com defines it this way: “a sudden, urgent, usually unexpected occurrence or occasion requiring immediate action. “
In my healthcare experience lifetime, perhaps nothing has changed more than the role of the hospital emergency room. In my youth the hospital had two roles: caring for very ill or post-surgery patients needing nursing care until they could be released home, and attending to accidents (think someone getting their hand injured by machinery or being in an auto accident).
As a variety of things have changed in our healthcare system over the years, there are some common beliefs about emergency rooms that we should take a closer look at.
Common Belief #1: Hospital emergency rooms must treat anyone who comes to their door.
Essentially this is true. Any hospital accepting funds from a government source is required to provide care to anyone who presents in the emergency room. The caveat to this understanding is that hospitals aren’t required to provide this care without charge, unless patients meet the criteria they have specified in their financial policies (usually available on the hospital website).
Common Belief #2: If you have insurance, care delivered in the emergency room is covered by insurance.
Not all care delivered in the emergency room is covered by insurance (this is the crux of Blue Cross Blue Shield of Georgia’s new changes as well). This common belief upended by change in the kinds of issues that emergency rooms end up treating, and they have often become de facto primary care centers, something they were never designed to be.
If a hospital operates an emergency room it is required to keep equipment and staff to take care of patients 24 hours a day, 7 days a week, whether for a crushed hand or a sore throat. The overhead to maintain this kind of readiness makes an ER, without question the most expensive place in our healthcare system to receive care.
Emergency room visits then are one of the most common causes of “Surprise” medical bills, bills that are significantly more than the patient was expecting.
Consider these typical scenarios:
- A 2 year old child develops a sudden fever; his parents are concerned because this has never happened before. They take their son to the closest ER where he is admitted, a number of tests are run to rule out a serious condition, and ultimately ibuprofen is administered. Their son improves and is discharged home. Three weeks later they get a $1200 bill for what seemed to be the simple administration of a medication they could have purchased at their local pharmacy.
- An elderly patient has had diarrhea that isn’t improving with Gatorade. She’s admitted at the emergency room, taken to the floor, and treatment with IV’s is started. She improves, and is discharged the next day. Thinking Medicare covers this since she was in the hospital, she is stunned to receive an $8000 bill.
- A 10 year old is riding a motorized scooter and falls off of it, hurting her arm. She is taken to the specialty children’s hospital where X-rays are taken, and her father is assured that she is OK and will recover uneventfully. The bill is over $3000. With their insurance allowance they owe $2000, but they have a $5000 deductible insurance plan and never dreamed it could cost so much to get X-rays.
- While visiting out of town, a woman begins to have chest pain. Unsure what to do, her friends call an ambulance. She is admitted to the emergency room, treated for an abnormal heart rhythm and told to see her doctor when she gets home. The bill was $19,000 and not covered by her insurance because her emergency care was limited to the service area of her insurance plan.
- A woman experiences severe abdominal pain. Worried, she checks WebMD and realizes that her symptoms are also consistent with appendicitis. She goes to the ER at 11 p.m., receives a CT scan, an MRI, and blood work, as well as pain medication and is advised that she has an ovarian cyst and should follow up with her gynecologist. The bill was $5000.
Emergency room visits have been steadily increasing, particularly as their availability has increased and especially as patients feel personal urgency (think back to that definition of emergency – a sudden, unexpected occurrence requiring “immediate action”) to their situation and are unclear about their options.
Because hospitals are the most expensive place to seek care, when patients access care at this level they are often stunned with the cost of their care. But, the reality is, no matter what care they received, they are paying for the most expensive overhead in the healthcare system.
Are there other options? In some rural areas there may not be good options, but if you live in a city of any size, there are ways to determine if this highest level of care is what’s appropriate for your situation.
Sudden. Unexpected. Requires immediate attention.
As patients, we know when something needs immediate attention. Profuse bleeding. Loss of consciousness. Chest pain. These are always reasons to seek immediate care. The challenge is when a situation feels like it needs immediate attention, but we’re not sure. And if you’re not sure, and don’t feel you have time to explore other options, it is always better to be safe than sorry and deal with the cost considerations later. But if you do have time, even 15 minutes, before making a decision, consider these options before you go to the emergency room.
- Most insurance plans have a 24-hour Nurseline. These services are staffed by registered nurses who can help assess your situation and can provide direction, including whether your situation can be addressed at home. They are usually trained to offer other treatment options that your plan may cover that would also provide appropriate care at a much lower cost. The calls are monitored and documented. If you’ve called your Nurseline and they tell you to go to the ER, you have a leg up in negotiating with your insurance company if for any reason they don’t cover the charges.
- Especially if you have responsibility for a child or other dependent, or have a chronic condition yourself, talk to your primary care doctor about what kinds of issues might occur for which you should go to the emergency room. Also ask how the practice wants you to communicate and seek advice for something sudden and unexpected. With the fragmentation of our system you may be guided to “go to the emergency room” but again, if you’ve followed your practice’s protocol for notifying them, you are in a better position to negotiate the cost of care if your insurance doesn’t fully cover it.
- If you are a Medicare beneficiary and you seek care in the emergency room, ask what your care status is. You can be taken to a room and cared for under “observation status.” Observation status may look like you’ve been admitted to the hospital, and is allowed for as long as two midnights/three days. Medicare differentiates “observation” as an outpatient care, which is covered under Part B. This has a big impact on your cost of care, because Part B covers outpatient care, and has a 20% co-insurance payment from the patient, which Part A doesn’t have. Read more here. This also has implication for post-discharge care so it’s important to know. Recent legislation that went into effect in March this year requires hospitals to notify you of your status (observation or admitted). This is a clinical decision that belongs to the treating physician, but always ask what your status is, and what would need to change for you or your loved one to be admitted so the care is covered under Medicare Part A.
- Consider seeking care at a lower cost facility. Urgent care centers are full service practices, typically staffed by physicians and supported by physician assistants or nurse practitioners. These facilities often have the ability to do X-rays and run labs, stitch wounds, and stabilize less severe injuries and illnesses until patients can be seen by their PCP or a specialist. Check your insurance website before an urgent situation occurs so you know which urgent care facilities closest to you are in your network. es with out-of-network care can occur at these centers as well so it’s important to make sure they are in your insurance network.
- Facilities like CVS Minute Clinic and Walgreens Healthcare Clinics are staffed by nurse practitioners, which can diagnose and prescribe medication, they have limitations around laboratory and other diagnostic testing, as well as what they can treat. They may or may not take your insurance, and you might find their rates higher than going to your PCP, but many consumers with minor illnesses find the convenience of these facilities outweighs the cost.If you’ve followed these steps and you get a bill you weren’t expecting, call our office. We can help.