It’s fall and all the emergency rooms are in bloom

I have noticed lately that there have been a bunch of “Emergency Rooms” cropping up and I wondered, is something bad happening around here? Are there that many emergencies? Is some pandemic, or outbreak of Chagas’ disease, hookworm or pellagra occurring?

Is Nostradamus finally about to be proved right, for crying out loud?

I would have probably considered the question for only a microsecond more, before occupying my thoughts with, who wrote the lyrics to Boomer Sooner, or why is it so hard to get grass stains out of my pants, or something like that, but then a patient asked me, is one of those little emergency rooms okay to go to, because there sure are a bunch of them all of the sudden?

I had to answer… maybe. It's not really a satisfying or reassuring answer, I know.

To really answer that question, I need to qualify whose criteria I am using when I talk about these places. There are billing differences for distinctions between “Type A”, “Type B” and Urgent care or clinic facilities set by the Centers for Medicare and Medicaid Services or CMS. So you are saying, I have private insurance why am I worried about that?

Because Insurers tend to follow CMS trends for reimbursement too. That’s why.

Type As get paid more than Type Bs and outpatient or clinic type settings.

If you are really curious I would refer you to: 42 Code of Federal Regulations 410.27 and in Chapter 6, Section 20.4.1, of the Medicare Benefit Policy Manual. Both are a riveting read!

In 2007, CMS divided ED visits into two types: Type A and Type B. Medicare defines a Type A ED as one that is available to provide services 24 hours per day, seven days per week (this requirement is also listed in the CPT Manual), and which also meets one or both of the following requirements related to the Emergency Medical Treatment and Active Labor Act definition of a dedicated ED. EMTALA compels the place to see anyone regardless of ability to pay, and “assess” or "evaluate" them. Additionally:

It is licensed by the state in which it is located under the applicable state law as an ER or ED

(and)

It is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.

A Type B ED is identical to a Type A in that it also must meet the EMTALA requirements and Designated ED definitions. The difference is that a Type B ED is not open 24 hours per day, seven days per week. Therefore, generally, from a CMS standpoint the key determinant is the time at which the facility department is scheduled to be open.

So, you may be saying, they really are pretty much the same.

Not so fast. CMS is not commenting on anything to do with immediate access to specialists, admission capability, proximity to beds, or access to certain procedures within an immediate geographic space.

Here’s how all that stuff fits in.

Let’s talk for a second about what an Emergency Department or an ER really is. First, it is a center, a place, where urgently or emergently injured or ill people can be evaluated, diagnosed, and referred/admitted/treated. So focusing on those terms we can assess some important patient care delivery differences.

Evaluation means triage and physical examination or assessment. It may or may not require x-rays or laboratory tests (like urine or blood) or special equipment utilization. This generally doesn’t have to involve a diagnosis, but really is an assessment of “how sick are you?”

Diagnosis means accurately determining what is wrong with you. Maybe I should refine that to say what is wrong that brought you in to seek an evaluation and care. I see people wandering around at the mall all the time and I say “what is wrong with that guy?” but I don’t think it’s something an emergency department could address.

Anyway…

Most ERs can address the first two topics, but consider the lone building ER. They generally lack the capacity for admission, should something require that and they often do not have the same immediacy of specialist support. So should your issue be greater or require surgical care or admission to a hospital ward, you are going to be need to familiarize yourself with Willie Nelson’s, “On the Road Again” because you will be sent or conveyed elsewhere.

Maybe that would be by ambulance. Maybe it will be by car. Regardless, it will be sort of inconvenient and potentially disruptive.

Additionally, if there is not an arrangement between the minor emergency or lone center and a ”connected” emergency department it could cause issues or delays. Now, if you just finished binge-watching the box set of the Sopranos, I am not talking about that kind of connected. I am talking about an ED attached to a hospital and if there isn’t an arrangement, you may be delayed for transfer or have to go farther out to another hospital.

And what about “urgent care”. Well they are more like your doctor’s office, and have hours when they are not open. For most cases the ascending level of severity appropriate for these facilities is:

Minor stuff, or things you might usually go to your doctor’s office for only after hours - Urgent care.

Moderately severe stuff – smacked your thumb with a hammer and the skin isn’t broken and it hasn’t lost nerve function or blood flow- “minor” emergencies- Type B.

Severe stuff – My leather mask wearing neighbor got me with the chainsaw again – Type A.

So what can you do? Well, first contact the stand alone ER in your area and ask what they do if you have a more serious problem than you thought. Ask how that transfer could affect your bill, who makes the decision, how far is the affixed ED?

Ask straightforward questions. What happens if I am having a heart attack and need a stent or catheterization? How would that be handled.

While this is by no means a comprehensive discussion, it is a good start to one. I hope it stimulates to ask a few more questions. So with your body in mind…

Be Well