When a patient with a sore throat, earache or other minor ailment heads to the emergency department for a cure, there are a raft of consequences every hospital is familiar with: longer waits for patients with more serious conditions, higher costs for the patient and the hospital, and the challenge of treating a patient in a less-than-ideal care setting. While hospitals are required by EMTALA to take care of all comers, leaders at Presbyterian Healthcare Services in New Mexico have been testing an innovative strategy for dealing with non-emergencies in the ED — they screen patients for more serious problems before sending them on their way to a primary care appointment arranged by the hospital.

"Every ED physician knows there are patients who have non-acute problems who show up," says Mark Stern, M.D., an ED physician at Presbyterian Hospital in Albuquerque and a member of the multidisciplinary team that redesigned the hospital's ED procedures in 2010.

Treating those patients drives up ED costs — especially for patients without commercial insurance — and what's worse, the patients themselves may not be getting the best care they could receive, Stern says.

"The cost of a sore throat could be $600" in the ED, he says, adding that patients could get "better service in a primary care physician's office for $120."

The new approach in the ED works like this: Incoming patients are triaged by a nurse, who quickly decides if the patient could be better treated in a less urgent setting. The patients are then brought back to be seen by a physician or nurse practitioner, who discusses the hospital's new policy and determines the best course of treatment. Finally, a patient navigator arranges a primary care appointment within the system or another provider of the patient's choice.

In 2010, Presbyterian Hospital in Albuquerque became the first of the system's hospitals to adopt the program, after six months of meeting with the Centers for Medicare & Medicaid Services, local advocacy groups and the state of New Mexico to assuage concerns. The first question that comes to mind, of course, is how a program that sends patients out of the ED complies with EMTALA, but hospital leaders say the ED fulfills the screening requirements required by federal law before deciding whether a patient should be directed to primary care.

"We asked all of those questions right off the bat," Jim Hinton, president and CEO of Presbyterian Healthcare Services, says. "We're more than satisfied our program meets the letter and spirit of EMTALA."

At first, the health system did struggle with bringing ED physicians on board, who are trained to treat all who come in and consider that a fundamental piece of their trade.

"Emergency physicians, our training is 'We are the safety net,'" Stern says. "Our job is to take care of anybody regardless of ability to pay. All of sudden we're shattering this mindset they've been trained with."

Stern worked closely with the hospital's ED doctors to develop parameters for referring patients. Irene Agostini, M.D., was initially one of the skeptics, but says she and other doctors were gradually convinced of the program's benefits, which has led to declines in both ED utilization and return visits from patients who had been navigated to primary care settings before.

Replicating these results may be tricky, though; as an integrated system with a health plan and a multi-specialty group with more than 100 physician practices, Presbyterian is able to balance the reductions in acute care payments — estimated at $70,000-$100,000 in gross charges a month — with the increased revenue to primary care physicians and lower costs to the system's health plan. There are economic concerns even within the system, Hinton notes, pointing out that the hospital still refers patients to other providers even if they aren't affiliated with Presbyterian, without receiving any compensation. And the system shoulders the cost of referring non-paying patients to their primary care practices.

Ultimately, though, system leaders say the program's success will be measured in whether patients begin believing that EDs aren't there to cure the common cold.

"The ultimate goal of the program is to change behavior," Stern says.

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