Up to half of the people who are treated at hospital emergency departments and trauma centers are under the influence of alcohol, experts say.

That may be a sobering statistic, yet a recent study found that emergency departments can capitalize on this “teachable moment” to discourage problem drinking in the future.

But laws in more than half the states permit insurers to deny payment for medical services related to alcohol or drug use and that can derail hospitals’ best intentions, experts say.

Faced with the prospect of not getting paid for care, some emergency department personnel may sidestep the problem by simply not testing patients’ blood or urine for alcohol.

In the study, published online in the Annals of Emergency Medicine in March, nearly 600 emergency department patients who were identified as hazardous or harmful drinkers (defined for men as drinking more than 14 drinks per week or more than four on any single occasion, and for women as more than seven weekly drinks or three on any one occasion) took part in a seven-minute interview.

During the interview, an emergency department staff member discussed the link between a patient’s injuries and alcohol, as well as guidelines for low-risk drinking, and encouraged the patient to discuss what was stopping him from drinking less and to set a drinking goal.

Compared with those who received standard care, patients who took part in the sessions reduced their average number of weekly drinks significantly as well as their episodes of binge drinking and drinking and driving over the next 12 months.

“In the emergency department on a weekend, all the cases may be drug or alcohol related, and yet we don’t do” screening and intervention, says Gail D’Onofrio, the study’s lead author who is chair of emergency medicine at Yale University School of Medicine. ”Our goal is to normalize this in the emergency department.”

Although some of the nearly 4,000 emergency departments screen patients for drug or alcohol use, it’s not required. Level 1 and 2 trauma centers, however, which are typically equipped to handle emergency patients suffering from serious injuries sustained, for example, in major car accidents, must screen for problem drinkers. Level 1 trauma centers must also be able to provide counseling.

More From This Series: Insuring Your Health

Such screening and counseling can be effective, says Larry Gentilello, a trauma surgeon who has published studies on injury prevention and substance abuse.

“Most of the people who are injured don’t need to go into treatment,” he says. “They aren’t alcoholics or alcohol dependent. That’s why one counseling session can help them by talking about the risks of drinking.”

The extent to which so-called alcohol-exclusion laws deter emergency medical personnel from screening and counseling patients for alcohol or drugs is unknown.

The laws have a long history. Since 1947, more than 40 states have passed measures allowing health plans to refuse to pay for care if the patient’s injuries occurred while he was under the influence of alcohol or, in some states, drugs, say experts.

As people came to understand alcohol addiction and the possibility of treatment, however, it became clear that the laws were counterproductive. In 2001, the National Association of Insurance Commissioners recommended against them.

Since then, at least 15 states have repealed or amended their laws and now prohibit exclusions of coverage for drinking or drugs, according to data from the National Institute on Alcohol Abuse and Alcoholism. Maryland and the District of Columbia are among them; Virginia’s law remains in place.

Regardless of state law, self-insured companies that pay their employees’ health care costs directly can refuse to cover employees for alcohol-related claims.

The laws have ensnared both problem and occasional drinkers.

In Washington state a law, RCW 48.20.385, specifically bars insurers from denying coverage solely because an injury was sustained as a result of the insured being intoxicated or under the influence of a narcotic. http://apps.leg.wa.gov/rcw/default.aspx?cite=48.20.385.

Gentilello describes the case of a Seattle woman who was celebrating her 25^th wedding anniversary and had a few glasses of champagne at dinner with her family.

It was a rainy night and she was dressed up and wearing high heels. As she and her husband tried to hail a cab, she tripped on a curb, fell and broke her ankle. In the emergency department, her chart noted that she had a few drinks.

Her insurer refused to pay. Washington subsequently adopted a prohibition on alcohol-related claims exclusions in 2004.

It’s unclear how frequently insurers continue to apply such laws to avoid paying claims. Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade organization, says the group doesn’t know what member practice is.

Cynthia Michener, a spokeswoman for Aetna, says that “to our knowledge” the company doesn’t apply such exclusions. Other insurers, including UnitedHealthcare and Humana, didn’t provide information about their practices.

But a professor who has written about such laws says there are indications that health plans continue to use them to deny payment.

“There are tons of these cases,” says Sara Rosenbaum, a professor of health law and policy at George Washington University’s School of Public Health and Health Services.  ”The only evidence we have suggests that these cases go on.”

“There’s no reason to think that insurers, eager to hold down costs, wouldn’t continue” to deny payment based on such exclusions, she adds.

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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.

By Shefali S. Kulkarni

Americans who turn up in the emergency room to get dental care aren’t lost, they’re probably just running out of options.

According to a new report from the Pew Center on the States, more than 800,000 visits to the ER in 2009 were for toothaches and other avoidable dental ailments.

“People showing up at emergency rooms for dental is really your sign that your system is breaking down,” Shelly Gehshan, director for the Pew Center’s Children’s Dental Campaign says. “It’s just not serving enough people. This is your symptom of a system in crisis.”

During times of economic crisis, state Medicaid programs often target dental benefits as their first budgetary cut, pushing low-income patients from the dentist office to the emergency room.

A Washington state survey of 53 hospitals found that during an 18-month period in 2008-09, residents made more than 23,000 visits to ERs for toothaches or other dental problems. Among the uninsured, patients with dental disorders were the most frequent ER visitors. – Pew Report

But the shift from Medicaid reimbursements to hospitals is still costly to states. Dental groups have long since said that ERs only provide temporary relief for dental emergencies and lead to reoccurring hospital visits, which burden taxpayers. “We’re spending in the worst possible way,” Gehshan says.

For example the report shows that in 2002 Maryland had a 12 percent increase in the rate of ER dental visits once the state stopped Medicaid reimbursements for private practice dentists treating adult emergencies. Florida reported more than 115,000 dental-related ER visits in 2010, and in Oregon a 31 percent hike of ER cases among Medicaid enrollees over a three-year-period.

Access to dental care is also creating the surge in ER visits. Safety-net facilities like community health centers are losing federal dollars and are unable to provide comprehensive dental care.

The report suggests several steps to alleviate this problem. “States committed to serving more low-income people should ensure their Medicaid reimbursement rates are high enough to cover the cost of care,” the report notes.

Gehshan says that 90 percent of dental care in the U.S. is done by private practitioners and the majority of them don’t accept Medicaid.

Another strategy includes implementing ‘dental therapists’ or providers that are similar to nurse practitioners in the medical field.

According to the report, dental therapists would be supervised by dentists and “could perform some services offered by dentists, including both preventive and restorative (e.g., filling cavities) care.”

Minnesota and some Native American Alaskan tribes are already using these professionals.

But the American Dental Association, which released a statement on Tuesday agreeing with much of Pew’s report, opposes the idea of expanding dental therapists in the U.S. The dental association challenges Pew’s projections of a decreasing supply of trained dentists and notes that relegating patients to “so-called ‘midlevel dental providers’ is wrongheaded.”

The ADA cites the Journal of Dental Education’s 2009 report that “both the ratio of dentists to population and the net number of dentists will increase, not decrease, contrary to what the Pew report states.”

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.

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.

The new clinic will be located in the Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Ste. 150, Everett, WA 98208.

The clinic will provide treatment for children, teens and young adults ages 0-21 needing non-emergency medical care in the evenings, over the weekends and during the holidays.

No appointments or referrals are necessary.

Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Everett.

In general, the cost — and time waiting — are less at urgent care clinics than they are at emergency rooms.

Hours of operation for Urgent Care at Seattle Children’s Mill Creek Clinic will be the same as Children’s Urgent Care Clinics in Bellevue and Seattle:

• Monday through Friday from 5 p.m. to 10:30 p.m. and

• Saturday, Sunday and holidays from 11 a.m. to 8 p.m.

Children’s Urgent Care Clinics are not intended for serious or life-threatening emergencies, hospital officials cautioned, and if a child being seen at a Children’s Urgent Care Clinic has an emergent medical need, the patient will be transferred to an Emergency Room (ER).

To help parents decide whether to take a child to the ER or to urgent care, Seattle Children’s has prepared a quick guide:

The number deaths due to suicide, accidents and opioid overdoses also fell, the report says

Overall, 12,959 people died in the county last year.

Of those, 2,060 fell under the Medical Examiners jurisdiction, including suspicious, sudden, unexpected or violent deaths.

 Other findings in the report:

• Traffic fatalities declined by nearly one-third over the past ten years, falling steadily from 220 in 2001 to 150 last year.

• While accidental drug overdoses declined from 2009 to 2010, they still comprised more than a third of all accidental deaths.

• Firearms were the most frequent instrument of death in homicides and suicides.

Opioid deaths down

There was a substantial decrease in the number of methadone and oxycodone deaths from 2009 to 2010.

• Methadone was present in 77 deaths in 2010, compared to 129 in 2009, and was the primary cause of death in 67 of those deaths in 2010, compared to 85 in 2009.

• Oxycodone was present in 77 deaths in 2010 compared to 105 deaths in 2009.

To learn more:

• For a copy of the full King County Medical Examiner’s 2010 annual report, please call 206-731-3232 or visit www.kingcounty.gov/health/examiner
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