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 or health 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% of patients 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

fashion and 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-first policy, 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 improved patient 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.

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 problems a Band-aid over a gunshot wound effect (OReilly). These physicians remain firm that the pay first policy fails to adequately address the true issues 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 Physicians policy 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.

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 the pay 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

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

(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 nonemergent 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 room open and available for adequate management of nonurgent patient concerns. This primary care office would be in collaboration with the hospitals already existing network of

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 care without 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

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 reported by 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 payfirst 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

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

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

(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.

(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.