Last year, about 80,000 patients left U.S. emergency rooms without treatment when told they would have to pay $150 upfront because they did not have a true emergency. In other words, they Left Without Being Seen (LWBS).

Hospital officials say the trend to upfront payments is a response to mounting bad debt caused by a surge in uninsured and underinsured patients, plus reduced reimbursements for patients who use the ER for routine care.

Recently the State of Washington implemented a three-visit annual limit on Medicaid enrollees for 700 conditions and diagnoses the state declared as non-emergent. The list includes chest and abdominal pain.

ER doctors argue that sore throats and ear infections do little to clog ERs and require no costly technologies. They say patients don’t know in advance if a chest pain is a sign of a heart attack or something less serious. Patient advocates say the strategy could discourage patients from going to the ER for true emergencies.

“Sometimes as doctors we don’t know. That’s why we keep you for 24 hours and do tests,” said Leigh Vinocur, MD, spokeswoman for the American College of Emergency Physicians. Its Washington chapter is suing over its state’s limits.

To complicate things, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) believe the proportion of patients who “Left Without Being Seen” (LWBS) should be a quality indicator for hospitals. That seems to be at odds with the upfront payment strategy which is actually meant to increase the number of LWBS patients.

What seems to be shaping up is a three-way tug-of-war between hospitals, the Federal government and the country’s largest hospital accreditation agency on the best way to manage ED overcrowding and still provide care to those who need it most.

According to the Centers for Disease Control and Prevention (CDC), Medicaid enrollees visit EDs about twice as often as uninsured people and Medicare beneficiaries, who in turn visit about twice as often as the privately insured.

Patients most commonly at high risk of LWBS are young males on Medicaid with low acuity illness who end up in the EDs of teaching institutions.

One such teaching institution beset with increases in wait times, ED boarding, length of stay, LWBS, and a steady reduction of external transfer, the hospital took a different approach to solving its problems than the one described above.

This hospital launched a comprehensive initiative to get patient flow under control and maximize capacity utilization. With TeleTracking’s help, its “Journey to Building a Patient Flow Management Center” had spectacular results which not only improved patient access to care, but made a sizable contribution to the hospital’s bottom line.

In the first 12 months after the program started, the hospital achieved a $1.4 million return on investment just on the improvement in LWBS rates.

Every day, hospitals must balance the problem of ED overuse for non-emergent problems with the fact that some patients who leave without being seen have serious health issues. It’s estimated that as many as seven percent of LBWS patients are admitted to a hospital within 24 hours after they leave.

We believe better capacity management is a solution to LWBS and delivering care to uninsured and underinsured patients, and one which doesn’t require any compromises.

What do you think?

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