Texas Emergency Rooms and Elsewhere Levy Fees for Some Care

The goal, they say, is to concentrate services on the really sick.

Feb. 21, 2012 -- Talk about adding insult injury. More and more U.S. emergency rooms won't admit patients until they pony up a fee of $100 dollars or more for nonemergencies.

The fees are meant to discourage people suffering from nothing worse, say, than a sore throat or a skinned knee from taking up time and resources better reserved for the seriously ill.

Both for-profit and non-profit hospitals are levying the charge.

Ed Fishbough, spokesman for the nation's biggest for-profit chain, HCA Healthcare in Nashville, Tenn., says the company first started imposing such fees in 2004, at one of its Houston-area hospitals.

The practice has since spread to 76 other hospitals in the 163-hospital chain. The purpose, he says, is to "help reduce crowding in the ER and to educate people about appropriate use of ER resources."

Critics of ER fees include the American College of Emergency Physicians, which says that 2 to 7 percent of patients determined to have nonemergency conditions are admitted to a hospital within 24 hours.

Patient advocacy groups, likewise, blast the policy, saying it discourages the sick from seeking help. "It seems the point of the policy is to put a financial barrier between the patient and care," Anthony Wright, executive director of advocacy group Health Access California, told Kaiser.

Either way, here's how it works at HCA:

You show up at the ER wanting treatment. A clinician checks you out, and decides whether your case qualifies as a true emergency. If it doesn't, but if you want to stay in the ER and get treated there anyway, you are asked to pay a fee, which, at HCA, runs between $100 and $150.

Pregnant women, children younger than 6 and people older than 64 are exempt.

HCA says it had 6 million emergency room visits at its hospitals last year. Of those, 314,000 (about 5 percent) were from people who, after screening, were determined not to have an emergency condition. They were offered the choice of paying the fee and remaining in the ER for treatment, or leaving and seeking treatment at what HCA calls a "more appropriate setting," such as a clinic or doctor's office. About 233,000 patients chose to stay and pay. About 80,000 didn't, and took a hike. It's unknown where they ended up.

Such ER fees are common now at other big, for-profit chains (including Health Management Associates of Florida, and Community Health Systems of Tennessee) and nonprofit hospitals, as well.

Tomi Galin, vice president for corporate communications at Community Health Systems, says patients who choose to leave "are provided with information about other community health resources for their non-emergency medical conditions." Imposing a fee, she argues, helps reduce costs for the patient and the hospital alike because "the ER is the highest cost environment to receive non-emergency care."

The U.S. Centers for Disease Control and Prevention says patients with non-urgent problems account for about 8 percent of ER visits. Other studies have put the figure considerably higher. One by Health Affairs policy journal in 2010 concluded it was closer to 27 percent.

The non-profit Midland Memorial Hospital in Texas implemented a $150 ER fee in 2009, as part of an exercise in cost-control, according to a Kaiser Health News story. Kaiser says the hospital had lost $14 million in 2008, in part because of millions of dollars in ER bills left unpaid.

Since imposing its fee, the hospital has seen a drop in debt, according to its chief financial officer, whom Kaiser quotes. He estimates that about 75 percent of patients with nonemergency conditions leave the hospital rather than pay the fee. "More people now know," he says, "that our ER is not a walk-in clinic or a primary-care office."

Jay Keltner, spokesman for the Healthcare Financial Management Association, which represents health care financial executives, told ABC News his organization has no estimate for the amount of money hospitals that have imposed ER fees might be saving.

He does say, though, that focus groups conducted by the FMA find that consumers increasingly want to know in advance what their medical services will cost. "They don't like to be surprised on the back end," he said.

A hospital's delaying talking to patients about cost, he believes, serves no good purpose. If the conversation happens early on, as when an ER fee is charged, the patient and the hospital can both confront how the final bill will be paid. If the patient cannot pay, he said, then the sooner the hospital can try to get him or her financial assistance, the better.