The title of this post is a play on the old ER maxim, "Treat' em and street em." Rapid turnover in the ER is our friend, and we all want to get the minimally ill and worried well out ASAP so we can focus on the truly ill and the unknowns in the waiting room and hallway beds. So we do our best to churn and burn through the cases where we can to free up scarce resources.
My recent post about the odd little things you see in the ER produced a few interesting comments on this topic, the gist being the not-unheard-of solution of performing an EMTALA screen and immediately discharging those who are determined not to have an "Emergency Medical Condition." As a manager of a practice which is highly motivated to capitalize on every possible efficiency, I can tell you that we have considered this practice at various times over the years, and we have never pursued it. There are a number factors which we considered to be adverse or prohibitive:
- EMTALA itself represents a major obstacle and potential liability. The statute requires a medical screening examination (MSE), but does not define exactly what an adequate screening exam consists of. Can a PA do it? How about an RN? What are the minimum acceptable components? The statute is silent on these topics, and case law is all over the map as to what constitutes a valid MSE. Each institution is left to set their own standards. If you choose to screen and street, and this practice ever comes under close scrutiny by a court or regulatory body, your procedures best be bullet-proof and followed to a "T" every single time, because this practice is generally viewed with extreme hostility. If you are found to be deficient in this practice, you may be in for the proverbial world of hurt. Most hospital adminstrators (nor practice administrators) will not have the intestinal fortitude to take this sort of risk.
- EMTALA also represents a poorly-recognized malpractice liability. Though this is not authorized in the statute, and case law expressly argues against the practice, many Medicare Quality Improvement Organizations (QIOs) have come to use EMTALA as a proxy for medical malpractice. In short, if you treat someone, and they proceed to have a bad outcome, the QIOs have been known to step in and allege an improper MSE and levy fines as well as other penalties. These fines are not covered by your Med Mal policy. Worse, once the door is opened, the QIO has carte blanche to review large numbers of cases and practices and can be very unfriendly in their approach and the exercise of their broad powers. Don't ask me how I know this because I cannot tell you. You do have the option of fighting this to an administrative law judge, but your case had better be strong, and if you were screening and streeting, I would not want to defend you. Remember that although EMTALA was intended to prevent improper treatment of poor/uninsured patients, no improper financial motivation is required to show a violation occurred.
- Then there's the simple Med Mal perspective. Never mind the Feds -- if you street someone, they will make a very sympathetic plaintiff (or, to be clear, you will make a very unsympathetic defendant).
- To undertake such a practice, you will need the approval and cooperation of your hospital. There are some well-designed programs out there that generally involve screening non-urgent patients and redirecting them to a hospital-owned urgent care clinic or something of the sort. If your patients do have access to something of this sort, then this practice can indeed serve as an essential pressure relief valve to your ER. Absent some alternative avenue of care, it's hard to see a hospital administrator signing off on such a plan. Many hospitals have core values, whether religiously-derived or simply a committment to community service, that involves providing charitable care to those who cannot get it elsewhere. To me it seems like telling patients to "piss off" without providing some care plan would be a very tough sell to your CEO.
- Most screening MSE programs would be of limited efficacy. In my experience, the most challenging cases, and the ones that are most consistent with "abuse" of the ER, are ones which you could not turn away from triage. I'm talking about the chronic recurrent abdominal pains, headaches, low back pains, febrile toddlers, etc. None of these can be dismissed as non-emergent without at least a physician performing an H&P on them -- there are potential life-threatening causes of each. So if the physican has to take the time to see and evaluate these folks, well, you've already provided the time-consuming portion of the service so you might as well finish off the job! Ditto for the uncommon/odd minor things. It's not clear to me that a policy could be crafted which would allow an RN to justifiably and defensibly turn them away from triage. It takes the judgement of a physician to know that there's no emergency, and that requires the doc to take the time to see them. Since these are the simple cases, it would probably take less time to reassure and discharge them (perhaps with a prescription) than it would to kick them out.
- Even a well-designed and operated MSE program is likely to be a money-loser. Understand that you would have to be consistent in the application of the policy with all your patients, even the well-insured ones. There is no ER case which is more profitable than the insured minor orthopedic injury. Quick, easy, and lucrative. (Don't blame me if the rules don't make a bit of sense; I just work here.) If you send away all your minor sprains and nondisplaced fractures, you are sending away a significant fraction of your revenue, and the easiest money at that.
- There's no way to generate more pissed-off patients and more complaints for your hospital than to block access to the ER. If you are in a competitive market: i.e., there are some insured patients, and they have treatment options, this will not go over well with your administration, less because of the cost than because of the negative publicity. The blowback may also have negative consequences for staff morale. Nobody likes feeling like a dick and blocking access to care.