Updated: Aug 15, 2021
Photo by Pixabay on Pexels.com
In 2017, there were 139 million visits to US emergency rooms according to data published in the annual National Hospital Ambulatory Medical Care Survey that can be found on the CDC.gov website, but according to that same publication only 10.4% of those visits resulted in an actual hospitalization. That means that of the 139 million ER visits, roughly 90% of those were evaluated and sent home. An ongoing question is: how many of those patients actually needed to be seen in the emergency room? How many elected to go to the emergency room because of the convenience of the 24-7 access? How many elected to use the ER because of lack of health insurance and lack of access to other options? How many chose the ER because their primary care providers did not have any available appointments that day and the patients could not wait for the next available appointment?
An even larger and more concerning question is: what does an unnecessary emergency room visit cost the patient? the insurer? the entire healthcare system?
In 1986 the US Congress passed the Emergency Medical Treatment and Labor Act (EMTALA) which required all hospital Emergency Departments that accepted payments from Medicare to provide an appropriate medical screening examination (MSE) to anyone seeking treatment for an emergency medical condition, regardless of citizenship, legal status, or ability to pay. Basically, participating hospitals were required to make sure all patients presenting to the emergency room were stable enough for hospitalization or discharge or transfer regardless of ability to pay. EMTALA is very specific in its definition of an emergency medical condition. An emergency medical condition is defined as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.” Unfortunately, a common misconception is that any care rendered in the emergency room will be covered under EMTALA and therefore uncompensated. So some patients will present to the emergency room with various illnesses that do not qualify as emergency medical conditions but still expect to receive “free” care. In reality, they now are unable to cover the cost of the services which will either be billed to the patient or remain an uncompensated expense for the hospital.
What if you actually do have health insurance and decide to use the emergency room for your walk-in office visit of choice because it’s more convenient? You might work until 6 pm and your regular doctor’s office closes at 5 pm, so instead of trying to get off of work a few hours early, you decide to just swing by the ER on your way home to get your UTI symptoms checked out. I mean, you’re only peeing more than usual. That doesn’t seem life threatening and certainly not severe enough to leave work early *gasp*. It’s really only a nuisance right now so you can wait until after work and you’ll just stop by the ER on the way home. BUT you soon find out your ER copay is significantly higher than your primary care office copay, you wait 90 minutes to pee in a cup while sitting in between someone who most likely has the flu and someone who might have tuberculosis, and you were just unknowingly charged an ER facility fee just for checking into the ER which will show up on the bill you’ll receive in the mail next week.
Some insurance companies are beginning to take action against unnecessary emergency room visits by deciding retroactively NOT to cover the cost of an emergency room visit at all. Most notorious of these insurers is Anthem, one the the nation’s largest insurers who has been largely criticized for retroactively denying payments on emergency room visits that were ultimately deemed non-emergent AFTER complete evaluations. A hypothetical example: a 45 year old male with a history of high blood pressure and high cholesterol who experiences chest pain goes to the emergency room because of concerns for his heart. After several hours in the ER which included blood work, cardiac studies, and imaging studies, he is ultimately diagnosed with heartburn and sent home. The bill totaling $8,000 would be denied by Anthem since his diagnosis ends up being a non-emergent issue thus the bill would then be the responsibility of the patient. Similarly, if a 21 yo female with right lower quadrant pain went to the emergency room because she was worried about appendicitis but was later told she had an ovarian cyst, she could be held responsible for that emergency room bill because an ovarian cyst is not considered an emergency condition. The insurer believes that this can be an effective way to reduce the number of inappropriate emergency room visits by its policy holders. Seems asinine to me. (Now, please note that this practice is not at all supported by the American College of Emergency Physicians, the American Hospital Association and the American Medical Association because of the wide overlap in symptoms between emergencies and non-emergencies.)
Besides the financial cost of an emergency room visit, there also is an enormous cost in resources. There is an undeniable strain on emergency room staffing– physicians, nurses, clerks, technicians; on space– waiting rooms, examinations rooms, beds; on diagnostic services– laboratory services, xray machines, CT scanners. More patients can fill the waiting rooms and examination rooms, but there are not more resources to cover the need. The true emergencies always will be and always should be priority.
So here are some things to think about when you are deciding between going to the ER or thinking about another option:
If you have been having back pain for YEARS and YEARS, today is not the day to finally get it checked out in the ER.
The ER will NEVER, I repeat NEVER EVER EVER, do an MRI on any body part. There will NEVER be a reason for an *emergency* MRI. I can’t think of one. So don’t go to the ER thinking this might be your chance to get that MRI that your primary care doctor is refusing to order. Not going to happen.
ER doctors don’t give second opinions. Think about it. Their entire profession is based on giving a really good first opinion only.
Emergency rooms don’t give out samples of medications like your primary care doctors. Don’t go expecting a sample of viagra.
Nowadays, good luck in getting pain medications from emergency rooms. That may have worked in the past. Now with the way things have become with prescribing controlled medications, you’ll be LUCKY if you get someone to say the words “pain medication” but if you do, it won’t be anything good.
Be prepared to wait. Don’t complain if you have to. It’s called a waiting room for a reason. It’s also called an emergency room for a reason.
Can this wait until your doctor’s office opens tomorrow morning? Does your stomach hurt “sooooo bad” that you need to go to the ER, but as soon as you get there, you send your friend to the Dairy Queen to get you a Blizzard while you wait? (It happens.) You can probably wait until tomorrow. Have you been coughing so bad that you can’t breathe but after waiting in the ER for an hour for that chest xray, you ask to go outside to smoke a cigarette? (It also happens.) You probably could have waited.
Can an urgent care clinic take care of it? Did you get a paper cut on your finger or did you cut your finger off with a paper cutter? Did you scratch your eyeball with your fingernail or do you have a nail in your eyeball?
Ultimately, trust your gut. No one is expecting you to know the difference between an appendicitis and an ovarian cyst but you do know the difference between wanting to take the next available appointment at your doctor’s office and not wanting to wait. Using the emergency room appropriately can save you time and money and can save the resources and staff for someone with a real emergency.
Manatee, watercolor. Fun fact, I belonged to the Manatee Survival Society in High School 🙂