ed policy women & globalization

7/22/2019 ED Policy Women & Globalization

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Karole Collier

Women & Globalization

December 21st, 2013

The Case Against Pay-First ED Care:

Recommendations to Effectively curb ED Crowding

Overview/Background

In the United States certain unalienable rights are granted to every American citizen.

Loosely, they are imagined to be the right to life, liberty, health, and the pursuit of happiness.

With the country recently settling the contested right to health

orhealth insurance,America

now awaits the largest shift to its healthcare infrastructure by The Patient Protection and

Affordable Health Care Act (PPACA) the largest reform of health care since the conception

of Medicaid/Medicare. Assuming the PPACA mandate stands true, the American College of

Emergency Physicians (ACEP) estimates that an additional 32 million Americans will have

health insurance by 2019 ((ACEP) 5). Unfortunately, in this country health insurance does not

always guarantee [better] access to adequate health care((ACEP) 2). As EDs remain the only

certain access point of care for millions of Americans, regardless of insurance status((ACEP) 6),

the issue of Emergency Department (ED) crowding continues to be an ever-increasing critical

matter of attention.

In the 2006 Massachusetts experiment, predating the PPACA and often cited as the

microcosmic study for PPACA implementation, there was no change in non-emergent use of the

ED; further, 56% ofpatients cited the inability to get an appointment with their PCP as the

reason an ED visit was utilized ((ACEP) 6). If Massachusetts serves as the nations microcosm,

32 million newly insured patients will enter a health system without any new predicted

commensurate capacity in access to PCP networks ((ACEP) 6)particularly in a timely


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fashionand will likely exacerbate the already critical issue of ED crowding. Furthermore,

non-emergent ED use continues to threaten the very foundation of the American emergency

health infrastructure via hospital debt, resource misuse, and inability to adequately follow-up

with patients care.

In an effort to curb ED crowding and encourage appropriate use of increasingly scarce

resources, some institutions enforce the pay-first policy. The pay first policy mandates patients,

whose problems are deemed nonemergent, to pay an initial fee to access ED care, or they are

given the option to seek care elsewhere. The pay first policy fees range from $100 to $180 for

uninsured patients, or the relevant co-pay or deductible for insured patients; in some hospitals it

has been reported to go as high as $350 (OReilly). Namely, the largest for profit hospital chain

in the world, Hospital Corporation of America (HCA)comprising of 165 hospitals and 115

freestanding surgery centers in 20 states and England has adopted the pay-first policy and

spread its implementation. (OReilly) Advocates of the pay-firstpolicy, and deferral of treatment

for non-urgent patients, cite advantages that include: improved ED performance through

improved throughput times, decreased waiting times, and decreased financial debt ((ACEP) 6).

Other potential advantages of the deferral of care include the appropriate location for nonurgent

care for non-urgent conditions, shorter wait times, and improvedpatient satisfaction ((ACEP)

6). HCAs company spokesman, Ed Fishbough quotes, [The pay first policy] has been a

successful part in helping to reduce crowing in emergency rooms and to encourage appropriate

use of scarce resources. (Gatewiz). He continues, This [policy] helps ensure the sickest

patients get treated quickly, and those who do not have an emergency have access to more

efficient, less costly care (OReilly). In spite of this, Fishboughs statement to many remains

flawed, as the lack of access to care remains a significant reason patients with non-emergent

presentation end up in emergency care facilities.


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Opponents to the pay first policy cite the pay first trend as severely misguided(OReilly).

Physicians worry the pay first policy unfairly targets patients with poor access to primary care,

and can easily result in tragedy as some seemingly non-emergent conditions quickly worsen and

become life threatening problemsa Band-aid over a gunshot wound effect (OReilly). These

physicians remain firm that the pay first policy fails to adequately address the trueissues of ED

crowding, and feel patients may wrongly decide to steer clear of the ED to avoid pay-first fees.

(OReilly)

Opponents to the deferral of care, a component of the pay first policy, cite negative

ramifications that include: delayed treatment of emergent medical conditions, increased

medico-legal risk, and the inculcation of certain unethical practices related to patients ability to

pay ((ACEP) 6). According to the ACEP, published literature has demonstrated conflicting

conclusions regarding whether patients can be safely identified and refused ED care based on

non-emergent presentation((ACEP) 6); further, emergency medicine researchers deem

charging first for non urgent care as unlikely to significantly cut wait times or reduce ED

crowding (OReilly). Currently, the American College of Emergency Physicianspolicy on

Medical Screening of Emergency Department Patients strongly opposes deferral of care for

patients presenting to the ED, and ACEP continues to believe that deferring care for patients to

the ED reflects void in the healthcare system ((ACEP) 6). The pay first policy meets

considerable amount of reservation in the Emergency Medicine community. This sizeable

amount of opposition reflects the moral and ethical dilemmas at play as widespread

implementation of the pay first policy mandate disproportionately affects a population of people

already vulnerable to poverty, marginalization, and chronic illness and this number is only

predicted to increase.


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Since HCAs adoption of the pay first policy, the six million ED visits to HCA hospitals

in 2011 has resulted in approximately 80,000 patients, deemed as non-emergent, to forego

treatment in order to avoid the upfront fees(OReilly). As the nation looks toward the second

stage of the PPACA, and 32 million people gain health insurance, the issue of overcrowding of

ED proves inevitable and imminently approaches a critical mark. By prediction of the

Massachusetts experiments remained use of the ED, the nation looks to exacerbate the problem

of ED crowding by influx of 13 million newly publicly insured patients a 56%

prediction((ACEP) 6).

By adopting the pay first policy in over 165 plus hospitals, particularly those within the

HCA chain and those following the trend, the nation faces a potentially major public health

concern, and potentially will compromise the very foundation of emergency care. Addressing the

shortcomings of thepay first policy is a matter of dire attention and necessity. The policys

questionable ethical and moral standing complicate the issue of ED crowding, and further reflect

failed and inefficient emergent care in the United States. The pay first policy proves inadequate

to address the full spectrum ED crowding, and thus it is pertinent and imperative other options

are explored.

This paper addresses the chain wide implementation of the pay first policy within the

largest hospital corporation in the world: HCA, a hospital corporation comprised of 165 hospitals

and 115 freestanding surgery centers in over 20 states (Hospital Corporation of America). With

the predicted 13 million-influx of patients nationwide, this hospital chain remains the largest

national healthcare provider, and looks to lose the largest amount of capital, patients, and quality

ratings if the pay first policy does not undergo critical review. HCA should recognize and

address the full spectrum of ED crowding via the input-throughput-output model and critically

assess solutions for each portion of the ED process. The recommendations of this policy

proposal are as follows: 1) address input crowding by recognizing the barriers to care for patients


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with common non urgent care issues, and setting up one 24-hour primary care physician office-

per hospital in collaboration with its respective hospital/emergency care room; 2) address

throughput crowding by recognizing the barriers to care within triage and room placement, and

enforce a Nurse and Physician Assistant (PA) triage team to provide comprehensive evaluation

at triage and expedite care of midlevel emergencies. Out of the many policy recommendations,

including the pay first policy, these two particular proposals jointly address the critical mass of

ED misuse that lead to multifaceted problem of ED crowding, and they effectively address the

full spectrum of social, medical, and economic barriers to care.

Recommendation

To understand the multifaceted issue of ED crowding, I reference Asplins et al

conceptual model of Emergency Department Crowding (Figure 1) to structure my policy

recommendations and implementation agenda. The conceptual model partitions ED crowding

into three interdependent components: input, throughput, and output(Asplin et al. 173). Asplins

et al. conceptual model is characterized by the delivery of unscheduled care, and carefully does

not prioritize potential causes of ED crowding (Asplin et al. 174). This model merely provides a

comprehensive conceptual framework by which one can study the causes, consequences and

potential solutions of ED crowding. I hope by including this model I further highlight the ways

by which the pay first policy inadequately addresses ED crowding, and support my two policy

recommendations for HCA as they hope to resolve a substantial portion of ED crowding and

alleviate the strong contention regarding the pay first policy provoked within the Emergency

Medicine community and nation.


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(Asplin et al.)

I propose the policy recommendation for HCA to recognize the critical barriers to care

for their patients with common nonurgent care issues. Given that the pay first policy outwardly

only addresses this particular population of people, I challenge HCA, with the imminent arrival

of 13 million new patients, to address the broader issues of non-emergent prevalence in the ED;

further to discourage its misuse by providing a working alternative for patients with non-

emergent conditions that neither penalizes them, or encourages them to forego treatment due to

their inability to pay. According to Asplins et al., the ED provides a significant amount of

unscheduled care, often because there is inadequate capacity for this care in other parts of the

acute care system (Asplin et al. 175). Patients can be either sent to the ED because other

sources of after-hours care are unavailable, or alternatively patients may end up in the ED

because their condition worsened before they could be accommodated by their primary care

physician/provider (PCP)(Asplin et al.). I propose HCA implements an initiative to set up one

24-hour primary care physician office per hospital, in collaboration with the hospital/emergency

care roomopen and available for adequate management of nonurgent patient concerns. This

primary care office would be in collaboration with the hospitals already existing network of


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primary care physicians, and allow people of the community the ability to schedule

appointments/ walk-in after-hours, and seemingly provide a buffer to ED misuse with

appropriate management of chronic illness for vulnerable populations. This recommendation

offers a central after-hours location that presumably will alleviate other barriers to care like

transportation and flexibility of PCP provider. This recommendation addresses the following

aspects of input crowding: unscheduled urgent care and safety net care, while simultaneous

encouraging access to longitudinal follow care for repeated users of the ED, a aspect of output as

referenced in Asplin et al.

The benefits to implementation of this policy initially curb a substantial amount of ED

crowding, and adequately address the majority of the multifaceted issue of Emergency Room

misuse caused by non-emergent presentation. HCA should look to this option as it provides

better appropriation of resources, fully addresses the needs of the patient, and extends a

relationship between Emergency Room physicians and primary care physicians of the hospital

network to encourage follow-up carewithout penalization or substantial amount of patient

population forging treatment. Though exact percentages, amount of money saved, or expended

cost by the pay first policy have not been reported, HCA can anticipate a substantial reduction in

cost spent on ED misuse, unneeded diagnostic imaging, and overall efficient utilization of

primary care resources, as patients who are given this option will presumably forgo ED crowding

and misuse when allowed the option to appropriate and convenient PCP care.

Ideally HCA should consider facilitation of this service as in-house, as many hospitals

centers, particularly those within the HCA network, are already well established in partnerships

with primary physician groups/offices in the community. HCA can first utilize and streamline

individual hospital-wide systems for patients to better identify openings in multiple primary

physician offices during regular business hours, to initially utilize already available resources.

This hospital wide system, particularly for the anticipated 13 million influx of newly insured


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patients, should be within already established and marked safety net providers. Respective

hospitals can streamline available appointments from PCPs in ZocDoc fashion, having a

kiosk/nurse available in ED waiting rooms to encourage and facilitate use. HCA should second

utilize possible outpatient surgery center/office/locations within the hospital during off business

hours to centrally locate the PCP after-hours community care office like Good Samaritan

Hopsital in West Islip, NY (Kenen). They can incentivize a rounding system of two physicians a

night to run the office, as they can increase client pool and establish a tighter connection within

hospital network. Residents and Physician Assistants in Family Medicine can supplement

workforce. HCA should third utilize a 24-hour, nurse maintained, triage hotline in conjunction

with both the Emergency Room and Primary Care Office, by which patients can call into

determine severity of illness or condition, and make appointments accordingly if deemed non

urgent. Patient population looks to be better receptive to primary care office that is in house and

available any time. Such implications were successful and deemed cost effective in articles of

solution for ED crowding in Nathan Hoots Systematic Review of Emergency Department

Crowding: Causes, Effects, and Solutions (Hoot and Aronsky 131-32), and all

recommendations have been successful in small-scale changes around the country, particularly at

University of California-Davis, as reportedby Robert Derlet and John Richards in Ten

Solutions for Emergency Department (Derlet and Richards 24-26).

Potential setbacks for policy implementation involve HCAs initial cessation of the pay-

first policy. HCA is the largest for-profit hospital chain in the world, and thus implementing this

policy would take full cooperation and support of the corporation to recognize the flaws of the

pay first policy, and true effort to revamp each hospitals institutional ED policy to address ED

crowding respective to individual geographic, patient population, and trauma level. Setting up of

a primary care physician network for nonurgent care would require hospitals management to

appropriately incentivize and arrange space to initiate after hours office start up, and adequate


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personnel to maintain seamless use. The medico-legal aspects of setting up an after-hour PCP

community care office also can be a factor. Emergency Room resources may not be able readily

available to be appropriated to primary care needs, thus budgeting for 24-hour PCP office would

have to come from institution wide reworking of budget, or individual research grants from

organization like ACEP. More significantly, just by initial Google research, a 24-hour primary

care clinic has never been implemented, and thus appropriate scheduling of hours may be more

appropriate for some hospitals rather than this 24-hour model; further a trial period to implement

several full programs at select chain hospitals should be considered for baseline research.

The stakeholders in this policy recommendation are grants from ACEP, the PPACA

sections: 4103, 4205, and 1501, HCA individual ED department advisors to incentivize

personnel, and HCA as they assess the predictive lost of revenue with the implementation of

PPACA ((ACEP) 4-5). However daunting these task, HCA has more than enough staffing, and

personnel to provide their institutions the ability to address ED crowding comprehensively

without penalization. HCA can recognize the better utilization of resources, and save a

considerable amount of money in taking ideas like these into consideration.

My second policy recommendation is for HCA to address throughput crowding by

recognizing the barriers to care within triage and room placement, and enforce a Nurse and

Physician Assistant (PA) triage team to provide comprehensive evaluation at triage and

expedited care of midlevel emergencies. PAs have the ability to not only triage, but also start ED

treatment at the earliest stage. They are able to supplement care to patients and are trained

effectively enough to supplement better management of patients with nurses. They are able to

practice and prescribe medicine. ((AAPA))The teamwork model at this stage addresses two

critical moments of ED treatment: 1) diagnostic evaluation can be coupled with triage process, or

at least started earlier (waiting for complete diagnostics is a major barrier to waiting in the ED

once triaged, if PAs can start this process earlier and comprehensively, ED physicians may be


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able to better perform their job at addressing the emergency quickly and effectively); 2) PAs

have the ability to determine or at least anticipate inpatient need at triage level, and thus can also

start patient in boarding processing earlier.(Asplin et al.)

HCA looks to gain from this second policy implementation as PAs have the ability to

start ED treatment at the earliest stage. They are able to supplement care to patients and are

trained effectively enough to supplement better management of patients with nurses and they are

able to practice and prescribe medicine. ((AAPA))The teamwork model at this stage addresses

two critical moments of ED treatment and thus better management of resources, times, and

patient care are all effectively addressed.

A tentative plan of action for HCA is again seamless, as they already employ Pas, and

underutilization of these personnel has remained a nation issue (Derlet and Richards). HCA

Hospitals first implement policy, and comprise a team of Emergency Room nurses, PAs, and lab

technicians to plan course of action and common pathways of care. This group should come

together to make individual Emergency Room map based off of prevalence of illness, and trauma

level, and relevant crowding. PAs can and should be more utilized at emergency room

forefront(Derlet and Richards). HCA then should train PAs already present in emergency rooms

to take triage station in company with nurse. They should encourage teamwork and incentivize

additional triage training with bonus.

Potential setbacks for this policy are implementation and PA availability. HCAs network

has the robustness to demand more from medical institutions and training schools to adequately

address shortages, if it becomes an issue. Other notable mentions remain that teamwork triage

better address primarily mid-level emergencies instead of full model, and this comprehensive

model also may take longer. However HCA everything looks to gain with this policy essentially

saves time and lives elsewhere in the system. It to date has never been largely done before


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(research wise- not certain), and slow implementation meets just drastic shifts in medical

community acceptance.

Other notable solutions to comprehensively address ED crowding are the following:

expand hospital capacity, stop boarding admitted patients in the emergency department, use

evidence-based guidelines to address imaging over utilization, change admitting patterns, and

expand the role of ancillary ED staff and hallway care (Derlet and Richards)My policy

recommendations together remain the most comprehensive and effective for the imminent issue

of PPACA implementation as it addresses many aspects of the aforementioned non emergent

care and crowding, but also actively changes the barriers care and accessibility to care more than

any other recommendation and for EDs that's a substantial issue.

Reasonably both policy recommendations would slowly be implemented after full

baseline programs have been established and researched for feasibility and predictive decrease

on ED crowding. HCA should adopt these policies within the next two years, or at least for select

hospital implementation to better prepare for influx of newly insured population and provide

better ED care to the nation. ED crowding effects marginalized, disenfranchised, and chronically

ill patients, it is important policys like pay first are address and critically reviewed as they

diminish and discourage appropriate access to care. HCA is not only the largest hospital chain in

the world, but also it is a corporation that prides itself to be a leader in change and innovation.

Both policy recommendations for HCA have the potential to significantly change the face of

patient care and Emergency Medicine forever

and America waits.

Works Cited

(AAPA), American Academy of Physician Assistants. "What Is a Pa?" American Academy of

Physician Assistants.


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(ACEP), American College of Emergency Physicians. "The Ethics of Health Care Reform:

Issues in Emergency Medicine- an Information Paper." 1-12. Web.

Asplin, Brent R., et al. "A Conceptual Model of Emergency Department Crowding."Annals of

Emergency Medicine 42.2 (2003): 173-80. Print.

Derlet, R. W., and J. R. Richards. "Ten Solutions for Emergency Department Crowding." West J

Emerg Med 9.1 (2008): 24-7. Print.

Gatewiz, Phil. "Hospitals Demand Payment Upfront from Er Patients with Routine Problems."

The Washington Post(2012). Web. December 12th,2013.

Hoot, Nathan R., and Dominik Aronsky. "Systematic Review of Emergency Department

Crowding: Causes, Effects, and Solutions."Annals of Emergency Medicine 52.2 (2008):

126-36.e1. Print.

Hospital Corporation of America, (HCA). "About Our Company."

Kenen, Joanne. "Hospitals Try New Approaches to Curb Emergency Department Crowding."

Kaiser Health News(2011). Web.

OReilly, Kevin B. "New Ed Drama? Hospitals Demand Upfront Fee for Non-Emergencies."

American Medical News(2012). Web. December 13th, 2013.

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