When a patient with a sore throat, earache or other minor ailment heads to the emergency department for treatment, there are a raft of negative consequences with which every hospital is familiar: longer waits for patients with more serious conditions, higher costs for both the patient and the hospital, and the challenge of treating a patient in a less-than-ideal setting.

While hospitals legally are required to take care of all ED patients regardless of their ability to pay, Presbyterian Hospital in Albuquerque, N.M., now sends many patients to primary care appointments for less serious ailments after an initial screening.

"Every ED physician knows that there are patients with non-acute problems who show up," says Mark Stern, M.D., an ED physician at Presbyterian Hospital and a member of a multidisciplinary team that redesigned the hospital's ED protocol in 2010. Treating those patients drives up ED costs and, what's worse, the patients themselves may not be getting the best care they could receive, he says.

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

Today, incoming patients to the ED are triaged by a nurse who decides if the patient should be directed to a less-urgent setting. The patients then are 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 with another provider of their choice; the appointments are made within 24 hours of the ED visit.

Hospital leaders say the screening fulfills requirements from the 1986 Emergency Medical Treatment and Active Labor Act that hospitals offer emergency services to all patients. Prior to implementing the policy, hospital staff met with officials from the Centers for Medicare & Medicaid Services, local advocacy groups and state officials to assuage concerns. CMS representatives worried that patients would complain about the new system, Stern says, but reported later that no patients actually had done so.

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

Irene Agostini, M.D., was one of the skeptics, but says she and other doctors gradually were 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.

Presbyterian leaders say they are able to balance the reductions in acute care payments — estimated at $70,000 to $100,000 in gross charges a month — with the increased revenue to primary care physicians and lower costs to the system's health plan. But some financial concerns remain, Hinton notes, pointing out that the hospital still refers patients to other providers even if they aren't affiliated with Presbyterian, without receiving compensation. And the system shoulders the cost of referring patients without the ability to pay their own primary care practices.

Ultimately, though, Presbyterian leaders say the program's success will be measured in whether patients stop showing up in the ED with nonemergent conditions. Since the program was launched, less than 5 percent of patients have returned to the ED with a similar problem within the next few days.

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



If it's not an emergency, pay first

Some hospitals are taking a different approach to reducing the use of emergency departments for minor health problems: charging patients who show up for what the hospital considers to be a non- urgent situation with an up-front fee. In 2004, a Houston-area hospital was the first member of the HCA system to charge an up-front ED fee for nonurgent care, according to HCA spokesperson Ed Fishbough. Since then, similar policies have been implemented at 76 of 163 HCA hospitals. The fees vary, but are typically between $100 and $150. "It has been a successful part of helping to reduce crowding in emergency rooms and to encourage appropriate use of scarce resources," Fishbough says. "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." In recent years, many non-HCA hospitals have developed similar policies.

The American College of Emergency Physicians, however, discounts the theory that patients with nonurgent problems cause overcrowding, noting on their website that the Centers for Disease Control and Prevention classified only 12.5 percent of ED visits as nonurgent in 2006.