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Breaking News: EPs in Conflict with Admissions Policies

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000428245.02222.fc

    Emergency physicians find themselves at cross purposes in today's profit-seeking, cost-conscious environment, mediating their professional duty of diagnosing and treating patients with stated and unstated mandates from their hospital owners to maximize profits. The CBS news magazine “60 Minutes” reported the results in December of a year-long investigation involving more than 100 interviews with physicians and other health care providers who said they were pressured by the for-profit Health Management Associates to meet targets for admitting patients, a charge HMA denied.

    The company said in a statement issued after the “60 Minutes” piece that the CBS news show “failed to identify a single patient who had been inappropriately admitted from any of the company's emergency rooms, including by the physicians interviewed. Neither ‘60 Minutes’ nor the physicians interviewed identified any admission decision in which a physician's medical judgment was overridden by an HMA executive, much less to defraud Medicare.

    “‘60 Minutes’ did not in any way dispute the admissions data it was provided by Health Management over the last several months,” the statement said. “That data demonstrated that admissions rates from the company's emergency rooms were in-line with national norms and consistent over a several year period. Instead, ‘60 Minutes’ relied entirely on disgruntled former employees of the company and former contracted physicians, several of whom are seeking financial gain through active litigation with Health Management.” (See FastLinks.)

    The Hospital Corporation of America (HCA) rolled out a program in 2009 to screen out emergency department patients with nonurgent conditions who could not pay up front fees, according to an article in Modern Healthcare. (June 14, 2009.) It is a troubling trend for patients and the emergency clinicians who must care for them, many emergency physicians said. Physicians who abide by what hospitals require could fail their patients, the payors, and themselves, putting their licenses and ethics at risk, experts said, and those who balk can lose their jobs and even their careers.

    Robert Bitterman, MD, JD, said the practice becomes a trend wherever HCA starts it. “If one hospital does it, then others follow suit. It's going on in Reno [and] Houston. It's a big trend,” said the president of the Bitterman Health Law Consulting Group and an expert in laws governing emergency care.


    “Some of our hospitals — less than half the last time I saw a number — have these policies, not company-wide,” said Ed Fishbough, the director of media relations for HCA. “This started at one of our hospitals in Houston in 2004, and some of our other affiliated hospitals began adopting it shortly after that. For them, it has been a successful part of helping to reduce crowding in emergency rooms and to encourage appropriate use of scarce resources. 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. The fees vary, but typically it's between $100 and $150.”

    The issue has experts in emergency medicine and the profession's leaders at a loss. “I realize that hospitals are doing this. It's a reflection that hospitals and the industry in general are becoming more focused on their bottom lines, from my perspective, and less focused on what's best for their community and patients,” said Arthur Kellermann, MD, MPH, who holds the Paul O'Neill Alcoa Chair in Policy Analysis at the Rand Corporation and is a longtime emergency physician and expert on the role emergency medicine plays in public health.

    Andrew Sama, MD, the president of the American College of Emergency Physicians, said emergency physicians sit between the community and the inpatient setting, making important decisions about whether patients are admitted or receive consults. “We are important stewards of those resources,” he said.

    Dr. Sama acknowledged that external pressures can influence clinicians, but he said EPs need to focus on evidence-based medicine and do the right thing for the patient and the family. He questioned the extent to which emergency departments contribute to the cost of health care, especially in light of a report from the Agency for Healthcare Research and Quality saying that emergency care accounts for only about two percent of the nation's total health care bill. (See FastLinks.)

    He added that the federal Centers for Disease Control and Prevention estimated that only eight percent of visits to the emergency department are nonurgent. (Natl Health Stat Report 2010;28:1; see FastLinks.) “One thing is clear to all of us. You are individually responsible for the ethical provision of medical care and the physician-patient relationship. Financial and contractual considerations should not be part of that process. I understand how some folks may be pressured to do these things.”

    Tremendous consolidation is occurring in the hospital business that may be creating unusual pressures in some circumstances, Dr. Sama said. “The AMA [American Medical Association] has, like ACEP, concerns about the principles of physician employment. Remember what you are there for. Take care of the people. The decision to admit someone to the hospital is one made between the physician, the patient, and the family with evidence-based good medical practice in mind,” he said, adding that problems should be brought forward.

    Robert McNamara, MD, a founder of the American Academy of Emergency Medicine and a longtime advocate for emergency physicians, said AAEM has been meeting with the Centers for Medicare & Medicaid Services and the Joint Commission about the lack of due process for emergency physicians. “Everyone has to have due process. We wanted to add wording that they cannot be denied due process for quality-of-care issues and for speaking on behalf of patients,” he said. “This has become a big issue. Doctors are being forced to admit patients who don't need it or to transfer patients who are poorly insured.”

    When a nonprofit hospital in the Pacific Northwest was bought by Community Health Systems, the small democratic group staffing its emergency department found itself facing a dilemma. The physician who headed the group asked that his name not be used because he feared he might be blackballed from future employment. That concern was also expressed by other physicians who spoke with Emergency Medicine News. Some often no longer had a job with the hospital about which they were speaking, but they said they were worried about the effect of publicity on their careers.

    “We were renegotiating our contract and were ready to sign it when the sale was announced. I was told I had to go in at midnight and sign the contract. It was a contract with CHS,” he said. The group had agreed to help the hospital by doing its own coding and billing in exchange for the hospital's help in partially recouping the costs of caring for uninsured patients. “Even though it was a three-year contract, they came back after us within six months,” he said. “They said we need to redo this.”

    He said corporate leaders from CHS attended meetings in the mid-sized city where the hospital provided care. “They were adamant they were not going to pay anything for the uninsured or help in any way,” he said. At one point, he said, a newly appointed chief financial officer told him he needed to minimize care at the door for Medicaid and uninsured patients. “It was just her and me there. I asked, ‘Do you want to rethink what you just said, or do you want me to go to my group and repeat that?’

    “CHS had its ‘blue book’ that set criteria for admission, etc., and we were told what they didn't want,” he said. Physicians were told insured and Medicare patients should be full admissions, he said, and “we needed not to use the observation code.” When he pointed out that patients could not be backed into observation status if they did not meet criteria for full admission, he was told not to worry about that.

    “Nothing was blatantly said about what they would do,” he said. “We read between the lines about Medicaid or the uninsured. We were supposed to do our best to turn them away at the door.”

    He asked the group members what they wanted to do after another six months of negotiation. Past contracts had yielded significant pay cuts, and the members were blunt: “We're done,” they told him.

    A CHS vice president at one point told him he had to accept the contract or the group would be terminated, he said. “I said, ‘Should I take that as a verbal termination or expect a letter?’” The group finished out its six-month clause and then left. Other members of the group were told they were welcome to stay, but most left. The hospital brought in a corporate group to take their place.

    Tomi Galin, the vice president of corporate communications for CHS, said all patients who come to the emergency department of a Community Health Systems-affiliated hospital receive a medical screening exam, emergency care, and stabilization, regardless of their ability to pay and in accordance with federal law.

    “Like other hospitals across the nation, CHS-affiliated hospitals have policies regarding payment for services provided in the emergency department, which may include collecting a fee for non-emergency services at the time services are provided,” she said. “The policies are beneficial because they help patients make informed decisions about where to utilize services. When patients choose other care settings for non-emergency conditions, health care providers can remain focused on patients with true emergencies, which helps reduce crowded conditions in the ER while also connecting patients with appropriate health resources for non-emergency conditions. These practices help reduce costs for both the patient and the hospital, as the ER is the highest cost environment to receive non-emergency care.”

    Ms. Galin said the decision to admit a patient is complex and is made only by a physician. “ED physicians generally do not have admitting privileges. If an ED physician believes a patient should be admitted, he consults with the patient's primary care doctor, a specialist, or a hospitalist who ultimately makes the decision about whether to admit the patient,” she said. “Physician contracts at our affiliated hospitals do not include admission targets, and physicians are not incentivized or penalized based on admission rates.”

    An emergency physician who worked for the Hospital Corporation of America said the demand to meet quotas heated up between 2007 and 2010. Hospitals would track every patient event and release the information in a spreadsheet each month to let doctors see their personal metrics. The first quotas instituted concerned patients with nonurgent conditions, he said, and physicians were expected to “opt out” half of the people who were rated as nonurgent by the nurse at triage.

    “That came first and then after that, they started to do the same with admission. Twenty percent was a benchmark,” he said. “They were subtle about it. They would have a nurse manager stationed in the ER from 7 a.m. until 7 p.m. She'd watch the screens as the patients came in, tracking in real time. She'd see what the labs and imaging showed and would look up the criteria in a book. Then she'd say, ‘Room 6 meets criteria. Are you going to admit them?’ Sometimes they needed to be admitted, and sometimes they didn't.

    “The manager would cover the flip side when you admitted someone, and they didn't meet criteria so we wouldn't get paid for it,” he said. Sometimes the patient was a social admit who could not be sent home, but the hospital was trying to avoid those to save on lost revenue, he said. Sometimes, he noted, doctors would receive emails from the director saying that admissions needed to be 20 percent. “I was in multiple hospitals. It was a new paradigm,” he said.

    Mr. Fishbough, the HCA spokesman, said many patients are excluded from the policy asking for upfront payments during triage, including children under age 5, those 65 and older, and pregnant women. “[A] clinician can make the determination that any patient should be excluded from this. Typically, our affiliated hospitals have two caregivers — usually a triage nurse and a physician — who make that determination.”

    Health finance experts said the policy to ask for upfront payments from patients with nonurgent conditions can prevent unpleasant surprises at discharge. Richard Gundling, the vice president for healthcare financial practices at the Healthcare Financial Management Association in Washington, DC, said telling patients upfront what they will have to pay avoids unpleasant surprises. “Patients don't like to be surprised at the end of procedure. They don't know it costs $500. Better patient communication is one of the things hospitals are doing. If the hospital asks for it up front and the patient doesn't have that, they can make alternative arrangements. The hospital can start that process,” he said.

    Dr. Bitterman said the practice of asking upfront payment from nonurgent patients began about 10 years ago. “HCA put a lot of pressure on their groups to do that under threat of potentially losing their contracts,” he said. “If one hospital in a market does it, the others often follow suit out of self-defense.”

    He said some hospitals do it the right way, helping patients arrange alternative care, but others “kick them out, and don't arrange for care.” This is done after a screening compatible with the federal Emergency Treatment and Active Labor Act (EMTALA), Dr. Bitterman said, though he said the program should be the same for everyone who shows up with a nonurgent problem. “You have to put everything through the same process. Some of them say, you have a UTI. If you want a prescription, you pay $100. I think that's unethical.”

    Dr. Bitterman said physicians need to check the ethical requirements of their state boards of medical licensure or their national associations such as the American College of Emergency Physicians before agreeing to that kind of policy.


    Triage does not count as an EMTALA evaluation, said Dr. Bitterman. Triage should include whatever examination is needed to decide if the problem is emergent, he said. Sometimes that can be a visual exam; other times a CT scan or a lumbar puncture. The concern, he said, is a policy that refers away patients without an emergency condition and that follows a preconceived notion of no benefit to the patient.

    HMA denied the accusations made on “60 Minutes” in written statements before and after the broadcast, citing a study they commissioned that demonstrated that their admission rates were no higher than those of other hospitals. CHS denied similar charges made by Tenet, another hospital corporation, in a lawsuit filed by Tenet when CHS attempted to acquire its Texas-based rival. CHS officials, in a PowerPoint presentation (see FastLinks), said:

    • Tenet's allegations of inappropriate admissions are based on contrived and biased metrics leading to a conclusion of implausibly inflated financial exposure.
    • If Tenet believes “observation rate” is a material statistic, then why did Tenet not disclose this metric in its own SEC filings?
    • Tenet is misleading about CMS's rules and guidance relating to the timing and utilization of observation status. Also, Tenet omits and understates the role and importance of physician judgment and decision-making in treating patients.

    A U.S. District Court in Texas dismissed the suit last March because it said Tenet had no standing to sue. CHS and HMA submitted documents as part of federal investigations, facts both revealed in filings with the Securities and Exchange Commission.

    Yet physicians, Dr. Kellermann among them, insist the problems continue, including that hospitals and decision-makers overestimate the numbers of people who come in inappropriately. “The issue of convenience or inappropriate use is about as widespread as welfare Cadillacs. The data, patient stories, and prior research have shown that when primary care and urgent care are not accessible, patients go to the one place where the light is on — the emergency room,” he said.

    And physicians are not always able to figure out quickly who is urgent and who is not. Research shows that emergency physicians have a false negative rate of three to six percent, Dr. Kellermann said, noting that patients are less likely to use the emergency department when medical homes or accessible systems of primary care are established, leading to fewer cases of unmet medical need.

    “A line I used many years ago is that when you tell people ‘don't come here until you are as sick as hell,’ that's what they will do,” Dr. Kellermann said. “It's the difference between refilling seizure medicine or treating status epilepticus.”

    These hospital policies also put emergency physicians at risk, he said. “They are telling the physicians who take the risk medically and legally to serve their bottom line. When your name is on the board and the triage nurse boots someone out the door or the physician assistant says they can leave unless they have a check, you as the emergency physician are subject to EMTALA. They will come after the doctor and not necessarily the hospital,” Dr. Kellermann said.

    “I hope ACEP, AAEM, and SAEM [the Society of Academic Emergency Medicine] can come together with a collective response that tells hospitals ‘we aren't going there. If you mess with one of us, you mess with all of us.’ The quickest way to shut this down is for any group to say it won't do this. When we sell our integrity, we have nothing left,” he said.

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