VISIT TO THE EMERGENCY DEPARTMENT

If you’ve ever visited an Emergency Department lately, you’ll be floored when you get the bill.
The 200 mg tablet of ibuprofen will cost you $8.  The same care is often much cheaper at an Urgent Care center.  The reason the cost  is so high is because the ED is located in the hospital.  Everything
is about twice as expensive if it happens in the hospital.  

Much of this is because, unlike the Urgent Care center, the hospital is required by law to treat every person that arrives.  18% of the US population (illegal immigrants, primarily adults >18 and < 65) have no insurance.  According to the CDC, another 61% of the population has private health insurance.  While it is not illegal for private doctor offices and Urgent Care centers to refuse to see people with no insurance, the hospital absolutely must care for the individual and the front door for the hospital is … the ED.  Often these individuals have postponed caring for their illness until the very last moment because they are marginalized by society due to low income or unclear visa status.  When the ED physician evaluates the sick individual, they are morally bound to admit the person into the hospital even though the hospital has little hope of ever being paid for their costs.

In recognition of this service to the community, the government (Medicare) has a special fee schedule that reimburses for services that occur within the hospital.  Even the insurance companies pay the higher rates. This allows for cost-shifting to take place to cover the care for the 1 out of 5 non-elderly US citizens (those under age 65).  When the 4 out of 5 patients with insurance come to the hospital, they pay twice as much.  This extra money is used to keep the hospital financially afloat to cover the charity care.  At some point, the private insurance companies stopped agreeing to pay this inflated rate and began insisting that their patients have any optional lab test, study, or procedure anywhere BUT the hospital.   The Giants (hospitals, Medicare, Insurance Industry) have gone to battle.   As you can see from just this one small example, it’s quite complicated and its unclear to me who are the obstructionists and who are the peacemakers.

It can be difficult to know when to visit the Emergency Department and when to visit the Urgent Care center.  As health care costs rise, the co-payments to visit the ED will increase making customers reluctant to stop by for an evaluation.  However, there are now Urgent Care centers becoming increasingly available.  Urgent Care centers do not operate 24 hours a day.  Many are closed on Sundays.  They are often staffed by Family Medicine physicians.  They are limited in what studies they can perform.  For example,
they certainly will not be able to send you upstairs for a head CT or MRI.  However, they could send you to a radiology center in the neighborhood that could perform that test within 24 hours.

Below is a list of the top 10 reasons individuals visit the ED in the US.  I will make a few comments about (1) Headaches and (4) Back Pain as far as what might make you glad you went to an ED instead of staying at home.

TOP 10 REASONS TO VISIT ED

1. Headaches
   
2. Foreign Object In Body
   
3. Skin Infection
   
4. Back Pain
   
5. Cuts/Concusion
   
6. Upper respiratory Infection
   
7. Sprain/broken bone
   
8. Toothache
   
9. Abdominal Pain
   
10. Chest Pain
    

(1) Headache

• The majority of individuals going to the ED with a headache will have a migraine headache.
  
• 1% of all those who go to the ED because of headache have a bleed.
  
• Unilateral headache with history of glaucoma could be a treatable eye emergency.
  
• Headache with any new neurological symptom (half-body weak, double-vision, slurred speech) could be a bleed in the brain and must be seen in the ED.
  
• This is an absolute if there was any recent head trauma!
  
• Headache and double-vision could mean tumor (blood, abscess, cancer) in skull.
  
• Headache with difficulty staying awake (people have to shake you or you fall asleep) following head trauma must be evaluated in the ED.
  
• Headache with neck stiffness (person does not want to move head) and fever must be seen in ED.
  

(2) Backpain

• Patients with a herniated disk dislike sitting.  They do not like to flex at the waist.  They prefer to lie on the unaffected side with the hurt leg bent.
  
• Kidney stones, gallstones, and pancreatitis are common causes of back pain.
  
• Backpain should improve with rest over 48-72 hours.  If it doesn’t then this is concerning.
  
• Diabetics, heavy consumers of alcoholic beverages, those that take oral steroids have additional risk factors for dangerous infections of the bones of the spinal column.
  
• Any change in the urinary or bowel habits is very concerning when it occurs in the setting of low back pain