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Indian River proposing $50 copay for ER


Even as lawyers research whether it’s legal for Indian River Medical Center to charge poor people copays, the hospital has decided on an amount – $50 – that it wants to get from people deemed medically indigent who come to the Emergency Room with non-emergencies.

That amount is more than three times the maximum paid by Medicaid patients and it includes no treatment – only an exam to determine whether the patient’s complaint is threatening to life or limb.

If the medical problem is deemed a non-emergency and the patient chooses to go ahead with treatment at the ER, they will be charged the full amount of care, “which could be in the thousands of dollars,” George Eighmy, hospital CFO, told the Hospital District Board at a recent Chairman’s Meeting. “And [the indigent patient] would be responsible for the entire bill.”

The hospital is banking that the emotional jolt of a $50 copay to an already sick or injured person would keep them away from the emergency department next time.

In the optimal scenario, according to Eighmy, patient navigators would connect the non-emergency patient to low-cost primary care physicians at Treasure Coast Community Health, Whole Family Health Center or the Health Department.

Interim hospital CEO Karen Davis made the $50 sum known to the Hospital District board last week after months of meetings over how to combat the crowded Emergency Room.

The charge seems intended more as a bluff than an actual fee since the hospital has no intention of going after people who don’t pay on the spot, Eighmy said. “It would be written off as a no-pay,” he said.

Presumably, that would not be explained to the patients. Instead, they will be told that if they go on to a different healthcare provider for their malady, the $50 fee would be waived or refunded. An expanded navigator staff would intervene with the patient, guiding them through a list of providers.

“That’s the best framework we would have,” Eighmy said.

But the copay is still in question.

The proposal has stalled over a clause in the Hospital District’s rules listed within a Special Act passed by the legislature. That clause reads “the indigent sick shall be entitled to medical care without charge, subject to the rules and regulations prescribed by said board of trustees,” and goes on to say, “such board may collect from patients financially able such charges as such board of trustees may, from time to time, establish.”

Prior to the Chairman’s Meeting where Eighmy explained the plan, the board learned that its attorney, Jennifer Peshke, had reviewed the clause and determined the copay was legal. But District Trustee Tracy Zudans asked for outside counsel to give a second opinion on the matter.

The hospital is pushing for the copay to solve an overcrowding problem at the ER, typically caused by patients coming in for routine or other non-emergency care because they have no insurance or money to pay a doctor’s office. With a navigator program already in place and funded by the District, indigent patients are still using the ER for primary care, hospital officials say.

The problem is widespread at hospitals around the country. Many approaches have been tried elsewhere, from 24/7 call lines to help people determine whether they have a true emergency, to opening hospital-run urgent care and primary care centers steps away from the ER.

Multiple studies show that copays, also referred to as financial penalties or cost-sharing, have not had much success reducing crowded conditions in hospital emergency departments since they were first allowed for Medicaid patients by the Deficit Reduction Act passed by Congress in 2005.

Along with not significantly deterring patients from coming to the ER with non-emergencies, the Medicaid copays, ranging from $3 to $15, proved expensive to administer. IRMC officials are braced for exactly that. The process Eighmy described would involve new hires not only as navigators but in billing and social services, and he admits the plan would cost the hospital money.

“If this goes through, we will be taking a financial hit, but I think it’s important,” said Eighmy.

The Hospital District covers the healthcare of any uninsured resident of the county, including undocumented immigrants, if they earn 150 percent or less of federal poverty guidelines; the District is considering raising that percentage to 200.

Cleveland Clinic, which is slated to take control of the hospital later this year, is currently working out its own new policy for indigent care after learning that IRMC functions as a so-called safety-net hospital that takes patients other hospitals won’t cover, apart from stabilizing them after their arrival in the ER.

The proposed copay at IRMC would go toward the cost of screening the non-emergency patient, not for any actual treatment. Eighmy described the process to trustees: “When a patient walks through the door, medical screening will assess the patient, diagnose the patient and determine the level of treatment. If the patient is determined to be non-emergency, they go over to our financial counselors.”

Those advisers find out if the patient has private or public insurance (Medicaid and Medicare are public insurance), or if they are “self-pay” intending to pay on their own.

“If they are determined to be District-eligible, we would say, ‘There’s a $700 screening exam fee.’ Based on that, the District normally pays about 12 percent of charges, so that comes to $87, of which you would be responsible for $50. If you want to have treatment, you have to pay $50 and then you would incur charges which could be in the thousands of dollars and you would be responsible for the entire bill.”

The counselors will then suggest treatment at a different location besides the hospital.

“And as a further incentive, we would be willing to waive the $50 if they are willing to go see the doctor,” Eighmy went on.

At that point, even the strongest copay supporter, Karen Deigl, seemed confused. “Why would you be charging the fee to begin with?” she asked. “They’ve done what they need to do.

“They came through the emergency room, that’s set, and that’s an obligation: they owe the $50 to the hospital. We would ask for it, and then they don’t have it, and we would bill it. If they could prove [they went to a doctor], we would reverse it. That’s an added wrinkle.”

“When we were talking originally about the hospital copay, we were talking about a very minimal copay,” said Trustee Michael Weiss. “Fifty dollars is lot of money if you’re indigent. That’s not $5.”

“It had to be higher than what primary care was charging,” answered CEO Davis.

“It has to hurt a little bit,” said Deigl, who is on the hospital’s emergency department diversion committee.

It took Miranda Hawker of the Health Department, who works daily with poor patients, to note the danger in such a penalty. “What I worry about is the potential that they have a condition that they do have to treat and now they’re afraid to go to the Emergency Department because they might incur a fee,” Hawker told the board.

After the meeting, District Board treasurer Allen Jones said the $50 copay may be more of a deterrent than lower copays generally found ineffective in studies.

He also said he feels “there are better answers” and that he is researching them further before presenting them to the board. In the meantime, he wants to support CEO Davis, who he said has personally taken on the hospital’s problem-plagued ER, and so far appears to be achieving significant improvement. The issue of the legality of the copay is being reviewed by the same attorneys working on the deal with Cleveland Clinic.

The board expects to have an answer by its next meeting, later this month.