Making good use of the emergency room – includes information on insurance coverage and on triage

Making good use of the emergency room – includes information on insurance coverage and on triage – Special Supplement

J. Tobias Nagurney

It’s a scene straight out of a television drama: sirens wailing, lights flashing, an ambulance racing through city streets. A paramedic hovers over the victim of a three-car crash, while the driver radios the hospital emergency room (ER). By the time the ambulance screeches to a halt at the emergency entrance, an orthopedic surgeon is on the way and a technician is poised to draw blood for typing.

The treatment room is stocked with sterile packets of supplies ready for use, a heart monitor waits nearby, and a portable x-ray machine stands just outside the door. A nurse unwraps a plastic mask, uncoils its tube, and turns on the oxygen. As the paramedics wheel the unconscious man into the room, the ER team is ready to do whatever is needed – even if that means performing a tracheostomy or other life-saving procedure on the spot.

Although this sort of high drama happens in real life as well as in prime time, the fact is that more than 55% of visits to emergency rooms are for minor medical problems or routine care – not for potentially life-threatening events. According to an editorial in the New England Journal of Medicine, excess charges for non-urgent care add an estimated $5 billion to $7.2 billion to the nation’s annual health care bill.

When money talks…

Statistics like these have not escaped the attention of cost-conscious employers, managed care organizations (MCOs), or other insurers. Back in the days when emergency visits were automatically covered by any decent health policy, people had little motivation for staying away if they thought there was a reason for going. Those days are over, however, now that health care costs have become a national obsession. Financial pressures are forcing consumers to think differently about the ER and about how they should use it. “Non-urgent” visits are not a trivial matter: they explain much of the overcrowding and long waits that plague ERs, they can divert attention away from critically ill patients, and they cost more than the same care delivered in other settings.

A recent study of six hospitals in Michigan found that a non-urgent ER visit cost the hospital $62, but patients were billed $124 – a markup of 100%. Hospitals say this isn’t as bad as it appears and that all but about 424 of these charges are eaten up by fixed overhead. Keeping an emergency department open and staffed around the clock is quite costly – and the meter keeps ticking whether or not patients are streaming through the door. Under federal law, anyone who seeks emergency treatment should be evaluated by a physician, regardless of insurance coverage or ability to pay.

Hospitals have to find a way to cover their unreimbursed costs, and privately insured patients are a better source than Medicare or Medicaid, which purchase services at below-market rates. Although the proportion of paying customers varies greatly with the location and type of institution, on average hospitals collect about 50 cents on every dollar they bill.

… insurers listen

In order to understand how hospital emergency departments fit into the spectrum of health care today, it helps to look at where they’ve been. During the 1980s, ERs got busier and busier: federal officials counted 99.6 million visits in 1990 – a 19% increase over 1985. This trend is hardly surprising, given that during the same period the U.S. population swelled and the number of Americans over 65 grew by leaps and bounds.

The 1990s, however, have brought a surprising downturn in the number of ER visits. There were 92.6 million of them in 1993 for example, and 90.5 million in 1994. Part of this decline can be traced to better access to routine care, thanks to doctors’ offices that stay open in the evening and on weekends, and to the spread of freestanding urgent-care centers that handle minor emergencies.

But the most powerful determinant of ER use appears to be the clout of MCOs. When the American Hospital Association took a close look at the downturn in ER use, they discovered that it was most dramatic in states where managed care is going strong. In regions where few people are enrolled in MCOS, the number of ER visits continued to creep upward.

Health maintenance organizations (HMOs) and other MCOS have zoomed in on unnecessary ER visits as a place where expenses can be cut. There are three main strategies for accomplishing this, all of which can send patients reaching for their wallets. Anyone who has to choose among managed care organizations should ask – before signing up – about policies concerning ER use. Some are more consumer-friendly than others.

Pay every time you go. The most basic way of holding down the use of services is to levy a copayment. In this kind of setup, patients pay a set fee (averaging about $50) for each visit to the emergency room. Theoretically this encourages people to think twice before running off to the ER for minor problems. But does it also discourage people with legitimate emergencies from seeking timely treatment?

To answer this question, Kaiser Permanante Medical Care Program in northern California (one of the oldest and largest HMOs in the country) commissioned a two-year study comparing ER use before and after a copayment was instituted. The problems that brought people to the ER were categorized by degree of urgency: always an emergency, often an emergency, sometimes not an emergency, and often not an emergency. Overall, people made 15% fewer trips when they were required to ante up. They also demonstrated good judgment: most who stayed away had problems that are classified as “often not an emergency;” researchers saw a very small reduction in visits for conditions that are “always an emergency.”

This study suggests that requiring people to chip in for ER visits is an effective way to reduce costs without detrimental effects on health. Still, there is some concern that a substantial number of people with conditions that fell short of being genuine emergencies may have delayed treatment unnecessarily or risked having a semi-urgent problem evolve into something more serious.

From a practical point of view, people shopping for a managed care plan will have a hard time finding an HMO that does not require at least a small copayment for a trip to the ER.

Pay if your crystal ball fails. A chancier method that some MCOs are using to hold down ER-associated costs is making reimbursement decisions after the fact. In other words, a person who is mistaken about the seriousness of his or her symptoms may get stuck paying for a trip to the emergency room. It sounds like a comedy sketch – the hapless patient suffering chest pain “wins” if it’s a heart attack and “loses” if it’s only indigestion – but in real life there’s nothing funny about this.

Five state legislatures were not amused, either, and passed laws saying that if the ER visit was for a complaint that a prudent lay person might consider an emergency, then MCOs have to pay. Nineteen additional states are considering such rules, and a federal law has been proposed that would require insurers to pay for ER visits, regardless of the diagnosis.

Pay if you don’t ask “May I?” Some managed care organizations are modeling cost-containment strategies on “Mother, May I?” In this childhood game, the player who fails to politely ask “May I” before following the leader’s instruction finds himself moving backward, not forward. The MCO rules are basically the same: forget to ask for authorization before heading for the hospital ER and the treatment won’t be covered; remember to ask and there’s no problem.

MCOs argue that pre-authorization has two main benefits: it improves quality of care by directing patients to an appropriate treatment facility, and it holds down costs for everyone by restraining people who might overuse the ER.

The best choice

Sometimes it is obvious that a trip to the nearest hospital emergency department is needed: a steel-worker falls from a scaffold, a previously healthy toddler has a seizure, an adolescent is found unconscious on an empty basketball court. Unable to speak for themselves, such people are delivered to the hospital by ambulance, frantic relatives, or kind strangers.

It can be much harder to tell whether an illness or injury requires an immediate trip to the ER. The patient or a family member must make a judgment call, often in a tense situation when the impulse to act is powerful.

Regardless of what type of insurance they have, people should start by calling their personal physician, saying that they have an emergency, and briefly describing the situation. They may be asked to come to the office immediately, or be advised to go to the ER.

If the family doctor isn’t available, deciding what to do can be a real challenge. One reason is that many symptoms have several potential causes. In the Kaiser Permanente study, for example, “always an emergency” conditions included myocardial infarction, pneumonia, and bowel obstruction. “Often not an emergency” symptoms included chest-wall pain, cough, and constipation. Without diagnostic testing, it may be impossible to tell whether chest pain is due to myocardial infarction or heartburn, whether coughing is related to pneumonia or to inhaling a minor irritant, or whether constipation is a serious problem or a nuisance. In many instances, a physician would fare no better at self-diagnosis than the average person.

Get to the ER, ASAP

Some problems always warrant an immediate trip to the emergency department because, if left untreated, they can quickly become life-threatening. Some of the major conditions that should always be considered urgent are listed here.

Severe abdominal pain. Because this may signal appendicitis, bowel obstruction, or the perforation of an organ, immediate medical treatment is needed if there is vomiting, swelling or tenderness of the abdomen, bloody diarrhea or severe constipation, temperature of 100[degree]F or higher, or pain focused in one area.

Breathing difficulty. A heart attack, pulmonary embolism (blood clod in the lungs), acute asthma, or a serious allergic reaction can interfere with normal respiration. A trip to the ER is essential if difficult breathing is accompanied by any of the following: history of underlying heart or lung disease, chest pain, rapid heart beat, sweating, loud wheezing, dizziness or weakness, swollen tongue or throat, pale clammy skin, or bluish discoloration around the lips.

Burns. First-degree burns (red, painful skin) are rarely an emergency. Second-degree burns, which typically cause blisters, merit an ER trip if they involve 5% or more of the body’s surface (roughly four handprints). Burns that extend through all skin layers and look white or charred, or that involve muscle or bone, are always emergencies.

Chest pain. People with a history of coronary artery disease or angina should seek help if pain begins during exercise and persists despite 10 minutes of rest or under-the-tongue nitroglycerin, if it begins at rest, or if a familiar pattern of pain worsens. Although lung ailments, indigestion, or even muscle strain can produce chest pain, this symptom is especially likely to signal a myocardial infarction if there is pressure, aching, tightness, or a crushing feeling in the middle of the chest; pain radiates down an arm (usually the left), which may make the muscles feel weak or numb; chest pain spreads to the jaw, neck, or back, or there is light-headedness, fainting, sweating, nausea, or shortness of breath.

Confusion and changes in consciousness. The sudden onset of confusion, memory loss, alertness, or awareness should be considered an emergency – especially in older people. Altered mental status is sometimes a sign of stroke or some other serious medical problem. Dramatic declines that appear over hours or days are particularly worrisome.

Fractures. A bone that is struck with sufficient force may break apart so that surrounding tissues, blood vessels, or nerves are damaged by its jagged edges. For this reason, most suspected fractures should be evaluated promptly at a hospital or urgent care clinic. (The exception is a mildly fractured finger or toe that may be splinted by a family doctor.)

Headaches. Even bad headaches are rarely emergencies: most arise from tension, migraine, sinus infection, poor posture, toothache, food additives (in susceptible people), alcohol, hunger, or excitement. In rare cases, persistent headaches are a symptom of a brain tumor or inflamed arteries in the skull (temporal arteritis). Most of these disorders are more appropriately handled in the doctor’s office than in the ER. Meningitis, encephalitis, or subarachnoid hemorrhage (bleeding inside the brain) are several causes of headache that constitute a true emergency. A trip to the ER is needed for a headache accompanied by any of the following: unusual drowsiness or confusion, nausea and vomiting, loss of sensation or muscle strength, fever, sensitivity to bright light, or abrupt onset of a headache of unprecedented severity.

Numbness or tingling. Numbness occurs when the blood supply to a nerve is temporarily interrupted; tingling signals the restoration of blood flow to the area. Carpal tunnel syndrome and other chronic conditions often cause these sensations in a localized spot – but this is no emergency. Widespread numbness and tingling can be due to a stroke or transient ischemic attack (a precursor of stroke). Get help immediately if one side of the body is affected; vision is blurred or distorted; speaking is difficult; parts of the body are weak, hard to move, or immobile; or the sensation is accompanied by dizziness or confusion.

Rash. This accompanies many viral illnesses and in susceptible people is a common reaction to certain foods, drugs, or environmental irritants. Though annoying, most rashes can be treated at home. Two specific types require immediate medical treatment because they can be signs of potentially life-threatening illness.

Purple spots on the skin and a temperature of 100[degrees]F or higher are signs of more serious illness, such as meningitis, especially if accompanied by headache, acute pain when the head is inclined forward, sensitivity to bright lights, or vomiting.

Hives are itchy, raised welts usually triggered by an allergy to food, drugs, or an insect sting. They constitute an emergency if they develop rapidly and cover a large area. Hives like this can progress to anaphylactic shock, a potentially lethal condition marked by dizziness, swelling of the tongue or throat, wheezing, or difficulty breathing.

Vomiting. This is an unpleasant but sometimes valuable protective mechanism that rids the digestive tract of poisons and contaminated food. Vomiting is usually an emergency if it produces blood or dark-colored material that resembles coffee grounds, which is probably due to bleeding in the stomach or upper bowel, if it is accompanied by severe abdominal pain, which could be caused by an inflamed gallbladder, appendicitis, or bowel obstruction or perforation, if a head injury preceded the vomiting by several hours or days and headache or dizziness occurs; if the vomiting is persistent enough to cause dehydration, especially in an older person; or if it is accompanied by headache, fever, pain on bending the head forward, sensitivity to bright light, drowsiness, or confusion. The latter combination of symptoms points to meningitis.

Thinking ahead

A time- and potentially life-saving strategy is to carry a wallet-sized card that lists significant illnesses, medications used, and names and phone numbers of personal physicians. Some patients with heart disease even carry a small copy of their most recent electrocardiogram.

Anyone with a recent illness or a chronic condition should know the signs and symptoms of complications, worsening health, and drug side effects. Make sure that the physician explains the warning signs to watch for; if possible, get them in writing.

In the overall scheme of things, there is no doubt that holding down health care costs is important and, clearly, curbing unnecessary ER use can contribute to this. It would be a real tragedy, however, if individual lives were lost or damaged because people stayed home when they should have headed for the ER.

Understanding Your

Emergency Coverage

Check with Your insurance company about the following:

* Do you need authorization before going to the emergency room?

* Is there a copayment for emergency treatment? Some HMOs require one for every ER visit, generally averaging about $50. Most Preferred Provider Organizations (PPOs) impose higher copayments if you go outside your network.

* What if an emergency happens away from home? U.S. hospitals outside a managed care plans service area can generally submit claims just as local hospitals do. But whether the charges are paid in full may depend on the diagnosis. If it turns out that you rushed to the ER with a non-urgent condition, you could end up paying part of the bill.

* What about outside the United States? Unless you purchased a special traveler’s policy, you’ll pay on the spot for any medical care received abroad. Some health plans permit you to file a claim after you return, but you’ll need every scrap of paper related to your treatment.

Medicare has its advantages

Medicare often keeps a looser rein on ER visits than managed care organizations. It usually covers all tests and treatments – regardless of what the problem turnes out to be. Reimbursement is for “Medicare approved” charges instead of the amount on the hospital bill. Medicare pays 80% of the approved charge and the patient (or a Medigap policy) pays the rest.

ER: The Real Life Drama

Time can pass slowly in the ER, whether you’re sitting in the waiting room watching your ankle swell or lying flat on a stretcher while people hurry past without a glance.

“What kind of service is this? I’m hurting! Aren’t these people supposed to be relieving suffering?” If this were a restaurant, you would leave and never come back.

The fact is that ERs don’t operate on a first come, first served basis. They work on the battlefield principle of triage (pronounced tree-azh). Triage has French roots and came into English as a military term. It is defined as the process of sorting victims to determine medical priority in order to increase the number of survivors.

In the ER, staff members quickly triage patients by asking specific questions, taking vital signs (blood pressure, pulse, temperature), and observing them. They know better than to rely on first impressions: a person who walks into the ER on his own may be critically ill, while some who arrive by ambulance have minor ailments.

Patients are assigned to one of three categories. Urgent means that immediate intervention is needed because vital functions, such as breathing, could be compromised. Non-urgent problems can wait: only minor treatments or reassurance are needed, and delay will not affect the outcome. In between are semi-urgent conditions, which need treatment as soon as possible but are probably not immediately life-threatening.

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