Ambulatory Care Quarterly
ED screening changes put pressure on competitors
Nonurgent cases may look for treatment elsewhere
When Ocala (FL) Regional Medical Center announced a new screening initiative that would involve counseling nonurgent patients to seek alternative care, a funny thing happened: Local competitors "Monroe Regional and Timber Ridge became involved when they heard about our initiative, because they felt they would be inundated by patients who were not having their treatment here," says Susan Atkin, RN, emergency department (ED) director.
The irony is that the initiative being promoted by her hospital’s parent firm, Nashville, TN-based Hospital Corp. of America (HCA), was itself the result of competitive forces in Houston.
"We got into it mainly because of our competitors," says Timothy Seay, MD, regional medical director for Greater Houston Emergency Physicians, a group of doctors who staff 12 hospitals in Houston and Corpus Christi, TX — all but one of which are HCA hospitals. "The screened patients coming out of their EDs were coming to ours."
Seay is unfamiliar with how the other hospitals screen their patients, but notes that "our goal is not to get them to another ED, but to an appropriate place. Another ED is a complete waste of time," he says.
The HCA screening process works this way: All patients are triaged using the five-level Emergency Severity Index (ESI) system, originally developed by the late Richard Wuerz, MD, in the department of emergency medicine at Brigham and Women’s Hospital in Boston. (Editor’s note: The American College of Emergency Physicians and the Emergency Nurses Association support the adoption of "a reliable, valid five-level triage scale,"1 of which the ESI is one.) In a five-level system, Level 1 is the most critical, and Level 5 is the least urgent.
"If the patients have no emergency medical condition, they are advised that they will need to speak to a patient financial counselor prior to care," Atkin explains. "They will determine a payer source for the patients or request a base rate payment for the self-insured patient."
Once a source of payment is determined, the care will continue. "But if the patients decide not to pay, and we determine there is no medical emergency, they are given a resource packet, which provides names and locations of the Department of Health, walk-in clinics, and local community health services for their follow-up care," she says. "Or they could be referred to their own [primary care provider]."
This process sounds familiar to Seay, and it should; it was his group that communicated the HCA initiative to Ocala Regional and West Marion Community, the two HCA facilities in Ocala. The Houston HCA facilities have been using this process since April 2004.
"We don’t charge on the physician side [for the screening]," he notes. "If they decide to stay, we send them a regular bill." The base rate referred to by Atkin is a hospital charge, which can vary from facility to facility, Seay explains. In Houston, a typical charge is $150, he says. The other special feature in the Houston system is that, in recognition of the large Hispanic population in that city, all resources also are in Spanish.
At Ocala Regional, the new process brought an additional challenge: They had been using a three-tiered triage system. While the five-level ESI system is not part of the new initiative, "all HCA hospitals are changing over to it," Seay notes.
In Ocala, the need to convert to a five-level triage scale meant a delay in implementation; in fact, the competitors already are running their new systems, while Ocala Regional is not.
"We needed to redevelop our triage form," Atkin says. "Then we needed to educate our staff on that five-level system. We sent about 90% of them to Triage First,’ a two-day class sponsored by HCA."
It was necessary "to refresh our staff about the importance of triage — to discern initially which patients are critically ill and need immediate help, who can wait a little while, and those who are not urgent," she notes. The hospital is waiting for a "go live" order from the administration, Atkin adds.
In Houston, the process has been in place for nearly a year, and it seems to be working well, Seay says. "We set out to decompress the wait room and get people to go to the appropriate place for care. There were no financial goals."
How does decompression work? "For every 10 people we have in the waiting room, our statistics show that seven will have insurance, and six of those seven will stay," Seay notes. "That means [under the new system] four will leave; so instead of a waiting room with 10 patients, you have six."
They have decompressed the waiting room by 40%, and in turn, the rest of the ED has been decompressed, Seay says. "The fast-track area has gone from chaotic to manageable, and we have thoroughly educated the population and changed acuity mix as well." The system is reinforced with an override option, he says. It works like this: A patient arrives and is triaged by the RN to Level 4 or 5. The patient is put in the medical screening exam room, and a provider — a doctor, a physician assistant, or a nurse practitioner — sees them.
"If the provider wants to do a test to see if an emergency exists, or if they do not think the patient should see a finance counselor before the completed ED visit, then they override the triage RN’s assessment of nonurgent," Seay adds. "This happens 20% of the time for us. We allow up to 30%."
Physician compensation includes incentive pay, some of which is tied to proper use of the override option, he continues. So, for example, if a physician exceeds the 30% ceiling, it could cost them,"at most, a few thousand dollars a year," Seay says.
The overridden patients then become traditional ED patients. "It is the clinical judgment of the examining provider, with the only rule being that there is substantial clinical certainty that no one goes to financial screening who could be sick," he adds. "If a test has to be done, then the patient is reclassified as potentially sick and is overridden and seen like a traditional patient. Most of this is transparent to patients."
Reference
- Emergency Nurses Association. Board of Directors meeting, Sept. 16, 2003. Formal statement regarding the joint Emergency Nurses Association/American College of Emergency Physicians Joint Five-Level Triage Task Force. Web: www.ena.org/about/position/default.asp.
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