By Phil Galewitz
KHN Staff Writer

This story was produced in collaboration with 

Next time you go to an emergency room, be prepared for this: If your problem isn’t urgent, you may have to pay upfront.

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation’s largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Led by the Nashville-based HCA, a growing number of hospitals have implemented the pay-first policy in an effort to divert patients with routine illnesses from the ER after they undergo a federally required screening.

At least half of all hospitals nationwide now charge upfront ER fees, said Rick Gundling, vice president of the Healthcare Financial Management Association, which represents health-care finance executives.

“It has been a successful part of helping to reduce crowding in emergency rooms and to encourage appropriate use of scarce resources,” HCA spokesman Ed Fishbough said.

But emergency-room doctors and patient advocates blast the policy as potentially harmful to patients, and they say those with mild illnesses such as sore throats and ear infections do little to clog ERs and do not require CT scans or other pricey technologies.

Kim Bailey, research director for the consumer group Families USA, said the tactic lets hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits. While the uninsured pay upfront fees as high as $350, depending on the hospital, those with insurance pay their normal co-payment and deductible upfront.

“This is certainly a concern to us,” Bailey said.

‘A Real Problem’

Physicians worry that sick people will forgo treatment. There is no data on how many who leave the ER without treatment follow up with visits to doctors’ offices or clinics.

“This is a real problem,” said Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours.

Patient advocates say the strategy could discourage patients from going to the ER for true emergencies.

“It seems the point of the policy is to put a financial barrier between the patient and care,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group.

The U.S. Centers for Disease Control and Prevention says that about 8 percent of ER visits are for non-urgent problems that could be treated less expensively in a doctor’s office or clinic; others put the number of non-emergency visits much higher. A 2010 Health Affairs study found that 27 percent of those visiting ERs could be treated more cost-effectively at doctors’ offices or clinics.

Reducing Bad Debt

In the past year, for instance, Iowa, Tennessee and Washington state reduced or eliminated Medicaid reimbursements for those visiting ERs for specified non-urgent conditions, such as sore throats or warts.

In an annual report filed last year with the Securities and Exchange Commission, HCA officials wrote that “we are taking proactive measures to reduce our provision for doubtful accounts by, among other things, screening all patients, including the uninsured, through our emergency screening protocol, to determine the appropriate care setting in light of their condition, while reducing the potential for bad debt.”

HCA says it complies with federal requirements to screen and stabilize anyone with an emergency. Of more than 6 million ER visits to HCA hospitals last year, 314,000, or about 5 percent, were determined not to be emergencies, Fishbough said. About 230,000 of those patients paid and remained in the emergency room for treatment. The other 80,000 or so left.

The HCA payment policy excludes children 5 and younger, pregnant women and those 65 and older.

“This helps ensure that the sickest patients get treated quickly and those who do not have an emergency have access to more efficient, less costly care settings,” Fishbough said.

HCA officials declined to say which of its hospitals use the practice, but the company owns more than 160 hospitals in 20 states, including Virginia, California, Alaska, Georgia, Missouri, Kentucky, Idaho and South Carolina.

Following HCA’s lead

Other large chains that have followed HCA’s example include Naples, Fla.-based Health Management Associates and Franklin, Tenn.-based Community Health Systems.

“These policies are beneficial because they help patients understand their financial responsibilities and make informed decisions about where to utilize services,” said Tomi Galin, a spokeswoman for Community Health Systems. “These practices help reduce costs for both the patient and the hospital.”

John Merriweather, vice president at Health Management Associates, said the 66-hospital system has seen a decline in wait times since it implemented upfront payments.

“We think this is appropriate, given that some people use the ER in a way it was not intended: as a source for routine care,” he said.

The upfront payments for non-urgent ER visits are also used by nonprofit hospitals.

In May, Halifax Health in Daytona Beach, Fla., began asking adult patients to pay their co-payment or $350 before treatment for a non-emergency in its ER, spokesman Byron Cogdell said. Like other hospitals, Halifax applies that fee to the patient’s bill.

Paying To Get Prescriptions

“If they don’t pay . . . they won’t be given their prescription,” hospital spokeswoman Michelle Leroux said.

The strategy is designed to help the hospital deal with spiraling, unpaid ER bills. About a third of the 120 patients treated daily in the hospital’s ER are uninsured. The change was implemented after the ER reported $1.3 million in bad debt for August.

“This amount of bad debt is unsustainable for our operation,” Skaggs chief executive William Mahoney said.

Midland Memorial Hospital in Midland, Tex., implemented a $150 upfront ER fee in 2009 as part of a cost control effort. In 2008 the nonprofit hospital lost $14 million, partly because of millions of dollars in unpaid bills from ER patients.

Since the change, the 320-bed hospital has seen a 10 percent drop in people visiting the ER with non-emergencies and a big drop in bad debt, said Stephen Bowerman, Midland’s chief financial officer.

In conjunction with the new ER policy, Midland set up a 24-hour telephone nurse triage system so people in the community can call a nurse to help decide whether to go to the ER or a nearby clinic.

Bowerman said the policy is helping to change behavior. He estimated that about 75 percent of patients with non-emergencies left the facility instead of paying the upfront fee.

“More people now know our ER is not a walk-in clinic or a primary care office,” he said.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Winds are expected to be 15 to 30 mph, gusting to 45 mph.

In addition, with the winds will come heavy precipitation tonight and Tuesday with a second weather system expected to bring more rain Tuesday night and Wednesday, the Weather Service said.

The heavy rain may cause some minor flooding in the most “flood-prone rivers,” the Weather Service said.

Rivers facing the greatest threat for flooding include the:

• Newaukum
• Chehalis
• Puyallup, near Orting
• Snoqualmie
• Stillaguamish

Be Prepared for Winter Storms: Tips from the Seattle Red Cross

Wind Storms

• Move or secure lawn furniture, outdoor decorations or ornaments, trash cans, hanging plants and anything else that can be picked up by wind and become a projectile.

• During the storm, draw blinds and shades over windows.If windows break due to objects blown by the wind, the shades will prevent glass from shattering into your home.

• Wind storms may lead to power outages. Prepare accordingly:

• Assemble essential supplies, including a flashlight, batteries, portable radio, at least one gallon of water per person per day and a small supply of food. For more information about building or purchasing a disaster kit, visit www.seattleredcross.org.

• Do not run a generator inside a home or garage. If you use a generator, connect the equipment you want to power directly to the outlets on the generator. Do not connect a generator to a home’s electrical system.

• Never use charcoal or gas grills as an indoor heating or cooking source.

• Only use a flashlight for emergency lighting. Due to the extreme risk of fire, do not use candles during a power outage.

• Turn off electrical equipment you were using when the power went out. Leave one light on so you know when the power comes back on.

• Keep refrigerator and freezer doors closed as much as possible. First use perishable food from the refrigerator. An unopened refrigerator will keep foods cold for about 4 hours.

Floods

• Be prepared to evacuate at a moment’s notice. When a flood or flash flood warning is issued for your area, head for higher ground and stay there.

• Eighty-percent of people who die as a result of flooding are in vehicles. If you come upon a barricade, turn around and go another way. If you come upon flood waters, do not drive through them; the road could be washed out underneath. If you are caught on a flooded road and waters are rising rapidly around you, get out of the car quickly and move to higher ground. Most cars can be swept away by less than two feet of moving water.

• If you are driving and your car stalls, abandon your vehicle and head to higher ground.

• Stay away from floodwaters. If you come upon a flowing stream where water is above your ankles, stop, turn around and go another way. Six inches of swiftly moving water can sweep you off of your feet.

• Be aware of flood hazards. Floods can roll boulders, tear out trees, destroy buildings and bridges, and scour out new channels. Flood waters can reach heights of 10 to 20 feet and often carry a deadly cargo of debris. Flood-producing rains can also trigger catastrophic debris slides.

For more safety tips and information on flooding please visit www.seattleredcross.org or www.redcrosswashington.org.

From FEMA – the Federal Emergency Management Agency

According to The American Red Cross, the internet – including online news sites and social media platforms – is the third most popular way for Americans to gather emergency information and let their loved ones know they are safe.

Through the use of everyday technology, individuals, families, responders, and organizations can successfully prepare for, adapt to and recover from disruptions brought on by emergencies and/or disasters.

With effective planning, it is possible to take advantage of technology before, during and after a crisis to communicate with loved ones and manage your financial affairs.

Stay Connected

• Keep your contacts updated across all of your channels, including phone, email and social media. This will make it easy to reach out to the right people quickly to get information and supply updates. Consider creating a group list serve of your top contacts.

• Learn how to send updates via text and internet from your mobile phone to your contacts and social channels in case voice communications are not available. Text messages and the internet often have the ability to work in the event of a phone service disruption.

• Keep extra batteries for your phone in a safe place or purchase a solar-powered or hand crank charger. These chargers are good emergency tools to keep your laptop and other small electronics working in the event of a power outage. If you own a car, purchase a car phone charger because you can charge your phone if you lose power at your home.

• Program “In Case of Emergency” (ICE) contacts into your cell phone so emergency personnel can contact those people for you if you are unable to use your phone. Let your ICE contacts know that they are programmed into your phone and inform them of any medical issues or other special needs you may have.

• If you have a traditional landline (non-broadband or VOIP) phone, keep at least one non-cordless phone in your home because it will work even if you lose power.

• If you are evacuated and have call-forwarding on your home phone, forward your home phone number to your cell phone number.

• If you do not have a cell phone, keep a prepaid phone card to use if needed during or after a disaster.

• Prepare a family contact sheet. This should include at least one out-of-town contact that may be better able to reach family members in an emergency.

• Have a battery-powered or hand-cranked radio or television available (with spare batteries).

The following are additional tips when making phone calls and using your smartphone during or after a disaster:

• Keep all phone calls brief. If you need to use a phone, try to convey only vital information to emergency personnel and/or family.

• If you are unsuccessful in completing a call using your cell phone, wait ten seconds before redialing to help reduce network congestion.

• Conserve your cell phone battery by reducing the brightness of your screen, placing your phone in airplane mode, and closing apps you are not using that draw power, unless you need to use the phone.

• If you lose power, you can charge your cell phone in your car. Just be sure your car is in a well-ventilated place (remove it from the garage) and do not go to your car until any danger has passed. You can also listen to your car radio for important news alerts.

• If you do not have a hands-free device in your car, stop driving or pull over to the side of the road before making a call. Do not text on a cell phone, talk, or “tweet” without a hands free device while driving.

• Immediately following a disaster, resist using your mobile device to watch streaming videos, download music or videos, or play video games, all of which can add to network congestion. Limiting use of these services can help potentially life-saving emergency calls get through to 9-1-1.

• For non-emergency communications, use text messaging, e-mail, or social media instead of making voice calls on your cell phone to avoid tying up voice networks. Data-based services like texts and emails are less likely to experience network congestion. You can also use social media to post your status to let family and friends know you are okay. In addition to Facebook and Twitter, you can use resources such as the American Red Cross’s Safe and Well program.

Get Organized

Store your important documents such as personal and financial records in a password-protected area in the Cloud or a secure flash or jump drive that you can keep readily available. This flash drive can be kept on a key ring so it can be accessed from any computer, anytime, anywhere. Remember important documents, such as:

• Personal and property insurance

• Identification: Driver’s License/Passport (for family members, as well)

• Banking information

• Don’t forget your Pets!

• Store your pet’s veterinary medical records documents online.

• Consider an information digital implant.

• Keep a current photo of your pet in your online kit to aid in identification if you are separated.

Your family may not be together when disaster strikes, so it is important to plan in advance. Create an Emergency Information Document or Family Communications Plan to record how you will contact one another; how you will get back together; and what you will do in different situations.

• Make sure to share this document with family members, friends and co-workers who will also need to access it in an emergency or crisis.

• When handling personal and sensitive information always keep your data private and share it only with those who will need access in case of emergency.

Sign up for Direct Deposit and electronic banking through your financial institution so you can access your payroll funds and make electronic payments regardless of location. Federal benefit recipients can sign up by calling (800) 333-1795 or at www.GoDirect.org.

Emergency Resources

Include these sites in your Emergency Information Document to ensure that you can quickly access them from any computer or smart phone.

• Download the FEMA App to access disaster preparedness tips, build your personal emergency kit, and look for open Disaster Recovery Centers along with open shelters (if you’re a disaster survivor). Also, stay informed with the FEMA blog.

• Local emergency management officials often have notification systems. Opt-In to a distribution for your community. To find out if your community offers such services, contact your local office of Emergency Management.

• Signup to receive a monthly preparedness tip from FEMA’s Text messages program.

• Bookmark important mobile sites:
  
  • Center for Diseases Control: m.cdc.gov
  • American Red Cross: www.redcross.org/mobile
  • FEMA/Ready: m.fema.gov
  • National Hurricane Center: www.nhc.noaa.gov/mobile
• Bookmark important online sites:
  • Your local emergency management agency, use Ready.gov’sState and Local Information page to locate your community’s direct information.
  • National Weather Service: www.weather.gov
  • American Red Cross Safe and Well:www.redcross.org/safeandwell
  • Save your meeting locations on your phone’s mapping device.
  • Google Crisis Response
  • Facebook Disaster Relief: www.facebook.com/disasterrelief
• Follow FEMA and Ready on line:
  • FEMA Blog
  • Administrator Craig Fugate on Twitter
  • FEMA on Twitter / Ready on Twitter
  • FEMA on Facebook
  • FEMA on YouTube
    
• In addition to using your cell phone and other technology, tune into broadcast television and radio for important news alerts. If applicable, be sure that you know how to activate the closed captioning or video description on your television.

• Important: In an emergency, you still need to call 9-1-1 for help. Remember that you cannot currently text 9-1-1. If you are not experiencing an emergency, do not call 9-1-1. If your area offers 3-1-1 service or another information system, call that number for non-emergencies.

More Information

For information on how web users increasingly rely on social media in disasters, please visit the Red Cross.

Disclaimer: Ready.gov/tech was created in cooperation with Google Crisis Response and the American Red Cross. If you have other tips to add, please contact us at Ready@FEMA.gov. FEMA does not endorse any non-Federal government organizations, products, or services.

The event includes presentations, workshops and activities filled with information and key resources for community members who want to prepare their families for a range of disasters, whether it’s heavy snowfall, an earthquake or a hazardous chemical spill.

Admission and parking is free.

Presentations include:

Talking to Kids about Disasters

Get helpful advice on how and when to talk to children about disasters and staying safe. Presenters include Kathryn Koelemay, MD, MPH Medical Epidemiologist Public Health – Seattle & King County and Dr. Doug Dicharry, a child and adolescent psychologist.

Safe Water Storage Tips

Experts from the Northshore Utility District will address crucial water storage tips, including how much to store, what kind of containers to use and where to store it.

Preparing Pets and Livestock for Disasters

Washington State Animal Rescue Team will share information on preparing pets and livestock for disasters, as well as interesting stories from their recent deployments around the country.

Onsite activities include:

• Build your own personal emergency kit with the help of Redmond business Prepare Smart

• Disaster response professionals from your community who will provide information on resources that are available to you and your family

• Special preparedness tips for seniors, children, the disabled, pets and livestock

• Tours of the Emergency Department and victim decontamination demonstrations

• Fire and emergency vehicles up close with demonstrations showing what they can do

• Puget Sound Energy High Voltage Demonstration

• Coast Guard appearance

• Special hazmat response vehicle from the National Guard

When:

Saturday, Sept. 24

Where:

Evergreen Hospital
12040 NE 128th Street
Kirkland 98034

To learn more:

• Visit the even webpage or call call the Evergreen Healthline at 425.899.3000