The news article that was released yesterday about Anthem refusing to pay ED bills for non-emergent conditions has brought the discussion of care vs. payment to the forefront.

I had read the article prior to heading out for my meetings of the day, and whether it was subconscious or not, it seemed to drive all the discussions I had with people throughout the day. Not just emergency care, but patient care vs. provider reimbursement vs. payer in general. I met with the CFO of a healthcare organization who told me how one payer had been declining payments for an unknown reason. After 10 months (yes almost a year), they had been back and forth with this payer, and out of the dozens of plans this carrier provided, had it narrowed down to one specific policy that was being denied. The problem was, they (the carrier) could not themselves explain why it was being denied, it was something with the system??

Tens of thousands of dollars being withheld from this small organization for no reason other than “the computer says so”.

I also spoke yesterday with an insurance representative who declared socialized medicine will be the downfall of the U.S. Look at New Zealand and what it did to their economy. Without the payers intervening to control payments, healthcare costs will skyrocket and care will become totally un-accessible once the gates open and everyone is allowed to seek care when they want.

I’ve met people who are proud of the fact they can go to the emergency room whenever they want, and others who lost their home because they have severe medical conditions and had to make the choice between their house or the medicine to stay alive.

Back to the ER article

In my years as an emergency room RN, I saw both sides of the debate. I saw a young mother of 4 who called an ambulance to transport her and her 2-year-old daughter to the ED because she did not have a car. I didn’t agree with her decision but didn’t voice my disagreement. I went so far as to give money to one of the ED techs and had them go buy a bottle of acetaminophen for her to take home. She came back 5 days later (again by ambulance) with another child for the same problem. I asked her what she did with the Tylenol I had given her, and she said it was already used up and she needed more. Seeing the pack of cigarettes hanging out of her purse, this time I did voice my opinion, and reminded her that the money for the pack of cigs would have gotten her 2 bottles of acetaminophen. This time before she was discharged, we set up appointments with a PCP located in one of our clinics just a couple of blocks away from her home.

On the other side of the scale, I saw a man who walked (more like crawled) in because he had blisters on his ankle and the pain had become so unbearable, he could hardly walk. He was triaged to the urgent care for his seemingly minor complaint of blisters. Turns out he had multiple fractures in his ankle and the blisters were caused by the excessive untreated swelling. After getting his history, we found out he had missed a step and fell from his porch 2 weeks(!) earlier and despite the pain had waited until it was no longer tolerable before finally seeking treatment. At this point his only option was to be admitted and taken to surgery to repair the damage. If he had come in at the time of the injury, would he have been splinted and sent home to follow up with ortho, and avoided the admission and emergency surgery?

All of us that have worked in the ED have the same or similar stories; The completely unnecessary visit (yes, I have the eye-roll perfected also), the “why did you wait so long to come in” visit (same eye-roll, different tone), and everything in between.

As a nurse I know that there are many instances of waste and abuse, but I believe they are not all to be blamed on the individual, but rather to the lack of education and understanding of healthcare in general. As a businessman I know the importance of cash flow and accounts receivable to stay afloat. I also know the importance of controlling costs and as a patient, I know how frustrating it is to be caught up in the middle of it all.

I hear all sides of the debate. I meet with payers, providers, and outside the office most people just know me as a nurse who does computer stuff so they share their stories with me. One thing they all have in common, their stories of what they think is wrong with the system. If everyone agrees the system is broken, there must be something wrong.

I would like to finish with some random thoughts.

What if people could seek treatment whenever they felt it was necessary, but triage nurses were allowed to guide them in the right direction for care, even if that means scheduling an appointment with a PCP?

What if people understood that they don’t need instant gratification and the emergency department is reserved for true medical emergencies?

What if payers trusted the providers to only give quality care and pay when it is given?

What if providers were held accountable for providing quality care and paid based on their results?

Whichever side of the debate you are on, it’s time for a change.