What's the basic difference between an emergency room visit and a doctor's office visit? In a clinic: "You are well until you are found to be sick." In an emergency room: "You are dying until we prove you are well. It's the safety net of the community," said San Juan County Hospital District Board meeting, Dr. Michael Sullivan the Emergency Medicine Department Chair of Peace Island Medical Center.
At the Hospital District Board meeting February 20, 2013 San Juan Islander Editor Sharon Kivisto asked questions about difficulties residents have had obtaining regular physician appointments and being directed to the Emergency Department instead. One letter-writer complained of a $700 bill for an earache and another thought a $1280 bill for 12 stitches was too high.
PeaceHealth Peace Island Medical Center Chief Administrative Officer Jim Barnhart said more clinic appointments will be available once PIMC finishes recruiting additional providers. PIMC will have four providers on staff when recruitment is completed.
Access will also improve once the current physicians are able to see more patients each day. They aren't seeing as many as they did at Inter Island Medical Center because of the learning curve involved in adjusting to the new processes.
He said PeaceHealth has set up the charges for Level One and Level Two services in the Emergency Department to be comparable to an office visit. The Level One charge is $105.
He said, "The emergency department has an obligation clinically and legally to work that patient up, in a more intensive way than happens in a medical office. And so that base level charge of $105 turns into some diagnostic work, sometimes it is an examination that requires equipment and procedures that is at a more intense level of care or service than happens in a medical office. And that is done to save lives. In some cases though in retro review it is unnecessary, in retro review. But on the surface the patient has to be viewed potentially in a critical state. There is triaging but it is more intensive care."
The legal obligation referred to is EMLTA, the federal law passed to prevent hospitals from refusing treatment to emergency patients. Barnhardt noted, not everyone who thinks their condition should have been treated by a primary care physician is correct.
Barnhardt explained why Emergency Departments cost more - they are fully stocked with state of the art equipment which is ready to go, fired up, turned on, for any patient need. The doctors have access to specialists. He said PeaceHealth set the rates comparable to its critical access hospitals in Ketchikan - 40 to 70% of mainland Emergency Room charges.
"When people choose for whatever reason to come through the door to the Emergency Department. I'm not choosing you are." said Dr. Sullivan. "We have access to all specialties...We are set out that way to save lives. How do you decide when somebody walks in and says 'I have a fever of 102' that you are suddenly an urgent care patient or you are in septic shock and you need to fly to an intensive care unit? How do you decide that?
"So you have to evaluate the patient. The charge that incurs in the emergency department that you're paying for when you walk in the door,you are paying for that facility to have all of that care available immediately. So that is where you are spending the bulk of the money. Are you spending the bulk of your money on the physicians services? No, you are not. You are spending the bulk of your money on the facility being ready to go, like a Ferrari, to rev the engine, to make sure you are going to be OK, and respond appropriately.
"It's hard to say, let's just make the first room of the emergency department an urgent care facility. How do you identify when you have 10 people in the room whose going to be urgent care patients because they are going to get the exact same service as the other people. It's not fair to the other people to suddenly go 'Oh it's only going to be this.'
"If we see people with simple office care visits we code appropriately. Level 1, I saw someone the other day with an infection I wanted to check to make sure everything is going well and get back to the surgeon... By the time you are seeing someone with prescriptions which could cause allergies you are increasing risks which increases the evaluation management code...Sometimes patients come in 'Doctor, I think I have strep throat' it's not that simple. We are definitely not padding the bill. If they need lab tests like rapid strep test they get it more quickly since we have priority."
"We're streamlining the time to get from registering to the physician. Everyday we've trying to improve... The scheduling template was built with 20 and 40 minute increments. Dr. Wingren worked faster than 20 minutes. Today I got a whole list of recommendations from the woman from Bellingham who worked to streamline the scheduling," said PIMC Administrative Director Beth Geiger. "With a new provider coming on board it will open up access...We've gotten new people in registration that are faster and that speeds up the process. ..I haven't heard of anyone that they couldn't get into the clinic and were forced to go to the emergency department recently, the last couple of weeks anyway, I think that's a good sign."
The best way to obtain a next day appointment is to call early in the day, be flexible in which doctor you will see and leave your number so you can be called in the event an appointment opens up. With appointments being tight, patients who arrive late may find they have to reschedule. It's not like the old days when you could be worked back in.
Barnhart said PeaceHealth does have financial help to cover out of pocket medical expenses even for people with insurance. The income limitation is 400 percent of the federal poverty line which he said is $92,000 for a family of four. The Bridge Assistance program would cover 10 percent of what it determined was an eligible expense at that level. Information about the program is available here.