Even as they face increased scrutiny over aggressive billing practices and are being urged to put a kinder, gentler face on collections, hospitals are trying new ways to get emergency patients to pay before they head out the door.
A handful of hospitals around the country are beginning to require emergency room patients to pay a portion of their bills before leaving the hospital. The new policies at hospitals in Colorado, Indiana and Wisconsin, as well as about a dozen other facilities nationwide, are being used to collect from uninsured patients, who are deemed unlikely to ever pay the full amount for services, hospital executives said.
Some hospital administrators also call the new policies a big help in reducing the patient load at emergency rooms because patients will be less likely to make a trip to the hospital with minor ailments if they know a price tag is attached. Although the American Hospital Association does not track how much hospital revenue is derived from ER visits, there was a 15% increase in emergency visits at hospitals from 1990 to 1999, according to an AHA study.
"This is not a local hospital problem," said Mark Mitchell, medical director of St. Joseph Regional Medical Center in Milwaukee. "This is more global." In October, Mitchell's 428-bed hospital started requiring emergency patients to either pay the copayment required in their insurance plan or a minimum of $150, Mitchell said.
"People come to the ER and someone has to pick up the tab," he said. "It is a fairness thing. We are not screening people out for economic reasons. We have to have resources available for those who need it."
Wishard Health Services, a 492-bed Indianapolis hospital that averages 108,000 emergency visits annually, is the latest to try collecting fees on site. Approximately 40% of the care the hospital provides is for uninsured patients. Excluding mental health cases, the emergency department accounts for 23% of the hospital's outpatient visits.
The hospital was planning to institute policies this week that ask emergency patients to pay a copay or point-of-service fee after treatment. The fee is a one-time charge based on the patient's income level.
"All of my faculty embrace and endorse the concept of patient obligation," said Rolly McGrath, Wishard's chief of emergency medicine. "If you have the ability to contribute to the cost of your care, you should."
The hospital will not turn anyone away but is hoping to get better financial results on the 70% of emergency bills it has trouble collecting. "We will not make the judgment on whether they should get care," McGrath said.
Patient advocacy groups are watching the issue closely. The Center for Patient Advocacy, a McLean, Va.-based grass-roots coalition of patients and patient advocates, has concerns about the practice because it could create barriers for patients who have nowhere to go for basic care but emergency rooms, a spokeswoman said. The practice also could lead to some patients being turned away who really need emergency care, she said.
The AHA has taken note of the challenges facing hospitals in efforts to collect emergency bills, not to mention the negative publicity that aggressive billing practices have received (Sept. 22, p. 32). The association issued a memo to its hospital members in June making several recommendations, including offering revised payment plans for patients who need financial help, and taking into account the amount of the charge and the patient's income and assets when determining a payment schedule.
The AHA also urged hospitals to hire collectors who treat patients with dignity and work on behalf of the hospital's values. "One of the challenges is that it is very difficult to know the patients who are unable to pay because of their limited means versus patients who may be able to pay but choose to be uninsured," said Carmela Coyle, the AHA's senior vice president of policy. "They have to balance that."
Patients who cannot afford the minimum payments before leaving St. Joseph in Milwaukee can talk to financial counselors and pay on a sliding scale based on income and family size, Mitchell said.
At the University of Colorado Hospital in Denver, which implemented its own program in October 2002, patients who arrive at the emergency room are given a medical screening to determine the extent of their ailments before they see a physician. After the exam, patients receive financial counseling and are required to make a deposit on the bill if they agree to be treated.
If patients do not want to pay the deposit, they are given a list of community clinics and the visit is treated like a trip to a medical office. Once the medical screening is performed and it is determined the patient is not in a life-threatening situation, the hospital has performed its legal requirements under the Emergency Medical Treatment and Active Labor Act.
"At our institution, emergency medicine was becoming unsustainable," said Norman Paradis, senior medical director of emergency services. "Essentially we were running a community clinic out of our ER."
In the first year of the billing practice, the 333-bed hospital reported about $1 million less in uncompensated-care costs, he said. The hospital also reported a 20% drop in the number of nonemergency cases treated in the ER.
"It essentially emptied our emergency waiting room," Paradis said. "We would have liked to provide minor medical care, but the funding for it went away completely. We keep the resources for those who are sicker."
Paradis predicts that more hospitals will require patients to pay a portion of their bill before leaving. Not only will the practice reduce the amount of uncompensated care hospitals provide, it also will make patients think twice before heading to emergency rooms for nonlife-threatening conditions.
"This is the most dramatic thing in my career," Paradis said. "My shifts run completely differently and I have much more time to be at the bedside of patients whose conditions are life-threatening."