- BIOETHICS FORUM ESSAY
But Wait, Call Now and Get Two ER Appointments for Only $24.99!
Emergency rooms hold a special place in the American health care system. They are the safety net of the safety net. Everyone who shows up has to be assessed, stabilized, and treated, regardless of one’s ability to pay. And everyone gets treated according to an equitable triage system: the most seriously injured or ill first, everyone else waits in a queue, often for hours.
There’s a new wrinkle in the system, however. Some hospitals will let patients register online or by phone and make an ER appointment for a specific time. The fee for this “premium service” ranges from $4.99 to $24.99. (Setting the fee at these numbers instead of $5 or $25 makes it seem like a TV sales pitch.) This fee is for setting up the appointment, not for the visit itself.
When you register with your name, complaint, and credit card information, you are given an appointment and assured your place in the queue. You can “relax at home while you wait.” And if you don’t see a health care professional within 15 minutes of your appointment, your fee is refunded. (It’s not clear if this professional is a triage nurse or a doctor.)
Many of the registration-for-a-fee systems are “powered” by InQuickER, a company based in Nashville. Hospitals using InQuickER are mostly in the South and Midwest. They like it because it brings people (and money) to the ER and maximizes the use of the facility. One spokesman for a hospital that pays $3,000 a month for the service said that he hoped that it would attract more patients with private insurance. Testimonials from patients suggest that many feel it is well worth the money to be assured of a place in line. So what is the problem?
Assuming these arrangements are legal in the states where participating hospitals are located, do they comply with federal Medicare and Medicaid policy? The federal Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals that receive Medicare reimbursement to provide appropriate services, including transfers where necessary, regardless of a patient’s ability to pay. Does offering a premium appointment service violate EMTALA, if not literally then in spirit?
Some of the hospitals offering this service include a disclaimer on their Web sites that if a patient with a true emergency comes in, that patient will be seen first and the registered patient’s fee will be refunded. But what happens when there are two patients with reasonably equivalent needs for care, neither of them true emergencies? Will the fee-paying patient be seen first so that the fee need not be refunded (and the patient not left disgruntled)? Letting some patients make appointments penalizes those for whom $24.99 is not a trivial sum, as well as those who are elderly or poor and don’t have access to credit cards, smart phones, or computers.
There is a broader health policy question as well. The patients targeted for this sales pitch have conditions that could be treated in doctors’ offices or urgent care centers. After all, someone who has a real emergency, such as uncontrolled bleeding or being unable to breathe, is not likely to be able to “relax at home while waiting for an ER appointment.” In addition to the information noted earlier, the person seeking emergency care has to check off a box affirming that he or she is not experiencing an emergency or life-threatening condition.
This non sequitur is more than semantics. One of the factors increasing health care costs in the U.S. is inappropriate use of the ER for conditions that could be treated in doctors’ offices or urgent care centers. Medicare, Medicaid, and private insurance pick up the tab when patients choose ERs instead of less expensive facilities. A provision of the Accountable Care Act prohibits health plans from requiring prior authorization for ER visits to discourage denials for visits where the condition might have been life-threatening but turned out not to be.
But health plans are encouraging members to choose urgent care centers in their networks instead of ERs, which are more costly to the insurer and to the patient as well, since copays are higher for ERs. Copays for ER visits run from $50 to $150, compared to $25 to $50 for urgent care centers or doctors’ visits.
With the number of ERs in the U.S. declining and the number of visits increasing, maintaining this service for true emergencies should be a priority. No one likes to wait in an ER, which can be chaotic and unpleasant. Still, introducing market values into the ER process commercializes one of the last bastions of fairness in our increasingly monetized health care system.
Carol Levine is director of the Families and Health Care Project of the United Hospital Fund and a Hastings Center Fellow.