It seems these days that the way to get things done in this country is to work through the courts instead of the legislature. This has been done successfully of late in several states by advocates for same-sex marriage. Now, California Emergency docs have sued their state for fair compensation from the state’s medicaid system (Medi-Cal). After a decade of unsuccessful lobbying efforts with the state’s congress, the docs of 5 EM groups have banded together in a class action suit to try to force some changes to the way they render care and are compensated for medicaid patients. To no one’s surprise, the docs claim that they lose money on every Medi-Cal patient they see (although other states may pay better, I don’t know too many ER docs anywhere that claim they make any average profit seeing medicaid patients). Some may say that seeing medicaid patients is part of a doctor’s obligation to treat patients and to some degree I agree. However, we are under a different set of legal obligations than all other docs (unless they are on call which technically, they can decide not to do). We have EMTALA which requires us by law to treat everyone that presents to the ER regardless of their ability to pay. No other docs have this rule. So as quoted in the article:
“The plaintiffs argue that DHCS violates the Equal Protection Clause of the U.S. Constitution and a section of the California Constitution because EPs are treated in an unlawful and unequal manner compared with non-emergency physicians, who retain the right to choose which patients to treat.”
They also go on to state:
“The suit also maintains that the plaintiffs’ medical services constitute a property interest because they offer the value of their medical education, professional experience, and actual care rendered. Providing these medical services to Medi-Cal patients without appropriate reimbursement results in a violation of the Fifth Amendment and the California Constitution, which prohibit unlawful takings, according to the suit.”
Whether this suit will be successful is up in the air (personally I think it won’t be), however it will be interesting to hear the debate on the subject (and how it will apply to any future health care reforms).
Here is my opinion on this. We all pay taxes to support our states’ medicaid funding. Doctors pay more on average because we make more than average income. This includes ER docs of course. However, we are also “paying” again to treat them in the ER at a financial loss (65 dollars max payment for a Medi-Cal patient does not even come close to cover operating expenses). Also, we are exposing ourselves to legal risk treating them (and thus pay higher malpractise premiums than most docs). So we are “paying” 2 * times! (The * is the potential for a lawsuit). Again, this is because of EMTALA.
My argument would be if increased payments to ER docs is not possible (due to a myriad of reasons), that we should get a tax credit for providing such care. If you work in an ER, you should get a tax break commensurate with how much medicaid care you provide because of EMTALA. I have no problem providing care to these patients but it makes sense that we don’t get double dipped (and then sued for our mandated efforts…..).
ER doctors are forced by Federal law to provide a very expensive service for free, so their income should be 100% tax-free. This gets a little sketchy if the doctors are employees of the hospital where many other departments are subsidizing their income, but, for sure, private ER doctors’ groups who are not employees of the hospital should receive a tax exempt status if they provide care to Medicare/Medicaideurs under EMTALA. I can’t think of any other group of people that are forced by the government to provide services to others for free.
For those of us non-medical people like me reading this blog in part in an attempt to better understand the healthcare debate in this country . . . can you explain the ER compensation system? I have been to the ER twice in the last 3 years (after, like, NEVER), and remember a copay and that’s it. No separate Dr bill, but of course we have real insurance . . .
So, does the hospital pay you based on how many patients you see and how they are treated? Or do you bill directly? I understand it may vary.
In general, I am surprised at how crappy Dr. pay really is and how hard it is to start or maintain a practice, especially in some states where malpractice is just insanely high! I think that the medical community should do a better job with marketing/media to get the message out there to the public. Most people still think that being a Dr is all golf fridays and rolling in $$$, after you get through all that studying . . . Most do not understand that government setting forced fee structures & crazy paperwork requirements based on arbitrary budgets is driving providers out of medicare/medicaid altogether. I mean, I think insurance companies are EVIL, however the government in charge of all this is a recipe for disaster.
Our MD compensation package is so confusing that the feedback from residents looking for post-residency jobs is that they didn’t consider our hospital because no one can figure out how much they get paid. From what I understand, it’s an hourly wage + an RVU bonus (based on #s and type of patients seen) as well as hospital-paid health insurance and 401K matching. Most of the compensation is an hourly wage though, which is why a lot of our doctors are LAAAAAAAAAAAAAAYZEE. There is no incentive to d/c the patient quickly because there is some point at which ordering a lot of tests on few patients makes you as much money as ordering an appropriate # of tests on more patients.
Other MDs’ groups are private, and are paid like any other physicians’ group for services—a physicians’ fee that is run through insurance and you get whatever the patients’ insurance company says you get which could be $20 for Medicaid or $350 for my insurance for the same service. One dood I know expresses his wages in terms of what he gets per patient on average including all the non-paying, Medicaid, Medicare, and private insurance combined.
All docs end up treating patients for free. Why should only ER docs are entitled to special treatment because of this?
I don’t think any of us mind losing money on an indigent patient that’s actually sick (MI, trauma, gangrene, lupus flare, whatever). But’s it is wrong to ask every doc to be forced to give her skills away for free to treat meaningless back pain, “I think I might be pregnant”, flu and other things that the privately insured patients would not get any medical care for.
The reason Anon (at least in the court argument) is that no other docs HAVE to treat the uninsured by definition of their job. They could technically not work in a hospital or not take any call and thus not ever see anyone who is uninsured. Of course most docs DO take call and work in hospitals so, yes, most do see the uninsured. However, the law technically prevents ER docs from working at all in their chosen field without seeing the uninsured/medicaid. Now, I personally think any doc who provides EMTALA care (like by taking call for the ER)should be able to write off their services on their taxes.
yeah anon the Er is the dumping ground of last resort
personally I think the cali suit will fail simply because the states broke and th state admins the medicare funds it gets from the federal govt.
Nurse K I think you have 2 problems with your logic
1. Your assuming the sole income of the er doc is medicare patients so there no way they get 100% tax deduct
2. if they belong to corp separate from the hospital why does that auto give them special tax status they are still an employee of a for profit corp.
Finally primary care docs are refusing to carry patients not on reg insurance because the lack of pay per service as well the cost to process the repayment by the govt and the delay in getting payment. These guys are losing money and all the billing/documentation costs are borne by the doc so why should ER docs get special treatment.
Conclusion the fed needs to fix our healthcxare system-hey I think ERP has posted this before sometime
“However, the law technically prevents ER docs from working at all in their chosen field without seeing the uninsured/medicaid.”
No it doesn’t. Freestanding ERs (in this area at least) do not take Medicare, Medicaid, TriCare, or uninsured patients. They can (and do) refuse service even to obviously ill or injured patients, turning them away at the front desk without ramification, because EMTALA only applies to facilities that accept Medicare.
Just a note… I’m insured to the max … I get bills but they say no record of my kid being there (she was)… and then vica versa … I go but no bill… it’s a Bigger Problem
Scalpel–Most ER docs aren’t looking to only see walk-in UTIs and strep throat in patients who don’t have any reasonable expectation of needing hospital admission. If they did, they’d be an internist ;-). Obviously YOU wouldn’t get my super special tax break.
Food Service Ninja—I think there should be a special exception for ER docs since, as I say, they are the only profession that I can think of that’s mandated by law to work for free if they choose to work in 99% of emergency departments out there. Not all care they provide is free, but it’s like saying grocery stores have to allow customers (whether it’s 20% or 100% is random depending on the day) to steal $300 or more dollars worth of food each and you are obligated to not even ask them to pay. In addition, if they don’t like the food or it gives them diarrhea, they can sue you for as much as they want. F that. You can’t tax them if they’re forced to give stuff away; it’s only courteous to allow them to offset the forced freebies by not paying taxes.
actually I’ve heard that some hospitals refuse to take my insurance…. way too much money spent on playing their rules … ie One private practice 3 ppl working insurance… that’s sick… Docs and Educators are undervalued in this country
Scalpel, I would not call such a facility you describe as an ER. It is a fancy walk in Urgicare place. And yes, I could work there and not deal with EMTALA but I would not call that practising Emergency Medicine.
You would be wrong. These guys are all fully qualified and very experienced ER docs who have done more than their fair share of charity care over the years and are now ready to profit from their expertise. The private ER is a valid concept whose time has come.
“We accept most medical insurance plans and all major debit and credit cards. We do not accept Medicare or Medicaid.”
My link didn’t work. Try this one.
I know it wasn’t the point of your post, but I want to address your comment about courts versus voting for same sex marriages. When the US Supreme Court struck down laws prohibiting marriages of people of different races most Americans still favored those laws. Mixed race couples were being denied their rights and if the courts had refused to address this injustice then those couples would have continued to be prohibited from marriage for who knows how many years. Today there are same sex couples raising children, maintaining homes, paying property and income taxes, and they must pay thousands of dollars in legal fees to have inheritance rights, medical decision making rights, etc. that hetero people like me get with a $50 marriage license. They deserve the equal protection of the law, without regard to the desires of others in our society to vote for that.
Sorry Scalpel. Still not an ER. It has to accept ambulances/911 calls (which means ALL of them, not just those with private insurance) – without that, it is just a fancy, albeit, well staffed and equiped doctor’s office. They have to transfer any admissions. Not an ER. Not that I think what they do is wrong but they are not really practising true “Emergency Medicine”. A free standing “Emergency facility” is not an “ER” or “ED” unless it is attached to and part of a full service hospital in my opinion.
Do they bill for “emergency services” to the plans they don’t accept? I bet alot of plans don’t consider them an ER either – they lump them in with non-particiapting outpatient docs and the patients pay mostly out of pocket.
Texas Reader, I agree with you.
Freestanding ERs accept ambulances, but in practice EMS doesn’t routinely transport to these types of facilities.
Some insurers balk at paying the ER facility fee for these types of practices, but they generally pay ER billing codes. The patient is responsible for the amount unpaid by the insurers, like with every ER (including yours).
All admissions have to be transferred elsewhere, but many rural ERs/hospitals have to transfer many of their patients too, so that criteria isn’t really a valid argument. A hospital-based ER doesn’t have to be a level 1-2 trauma facility to bill ER fees, nor do they technically have to follow EMTALA.
An ER also does NOT have to be physically attached to a hospital to bill for emergency services. This one, for example, does bill Medicare/Medicaid and so they must see all comers, but it is not physically attached to a hospital.
As for the billing issue – Most insurance plans (like mine),you just pay a copay for ER services. I pay a 50$ copay to go to any (not just one whose hospital is in my plan or whose docs participate)ER for emergency services. That is all I pay – I don’t get balance billed. My insurance pays the docs more if they don’t participate but it is not my responsibility and I am not balance billed. In the place you describe, I imagine the plan would NOT pay for the balance and the patient would be responsible for the remainder of it.
Also, I still argue the place needs to be 911 receiving to be a real ER. As for attached to the hospital – you might say not physically attached but it should be officially affiliated – they can’t just decide to transfer patients randomly and still call themselves an ER. Also, what if someone uninsured stumbles in and codes or is shot outside? I imagine they call 911 and the patient is transported across town to the county place. Again, not something an “ER” would ever do.
Not that I am saying running a place like this is wrong but it is an extension of our field of practise,not technically what we were trained and expected to do.
There are obviously different types of insurance plans, some companies are more willing to accept these models than others, and different facilities have different policies on balance billing. With an HSA, for example, you get the insurance discount but are responsible for the entire bill unless you have met your deductible for the year.
Some patients prefer (and are willing to pay a premium for) faster more personalized service rather than waiting hours in a busy waiting room with the dregs of society only to be treated like meat moved by overworked staff. That is their prerogative in a free country.
If a patient with a GSW is dropped off at the front door of a non-trauma hospital, I assure you that they are going to call 911 too. This guy shot himself INSIDE one ER and was transferred to a different trauma hospital. No difference, less paperwork.
Your opinion on how you think things ought to be is noted. I’m just trying to inform you how things are. Freestanding ERs offer full service emergency medical care more promptly and in a far nicer environment than most hospital-based ERs can manage. Having worked in some of them, I can assure you that they are indeed “real ERs.” They aren’t going away; there are dozens of them here, and more are being built every month.
We are a non-trauma receiving hospital and treat GSW’s (for both ethical reasons as well as the fact that we have to follow EMTALA)when they are dropped off at our doorstep – we have surgeons so they can be treated at our hospital but sometimes we do transfer them to a nearby trauma facilty for further care. Technically, this place could let them rot outside (and I guess do CPR or first aid) while the 911 ambulance arrives.
The point of these doctor’s suit however is that Emergency Medicine is treated differently than any other field of Medicine in that when we work in the way our training intended (ie, in an Emergency room, not a freestanding place or upgraded urgicare centre)we are forced by law to accept medicaid ( as well as everything else) payments because of EMTALA. This, as a result, the plaintifs claim, violates the state of California’s constitution by singling them (us) out.
You have it backwards. EMTALA doesn’t force you to accept Medicaid. If your hospital decides to accept Medicaid (and there is nothing forcing them to do so), then they must follow the EMTALA law.
Your training was intended to give you a skill set that you can use however you wish, including limiting your practice to only taking care of patients who pay you for your services. No physician is required to take Medicare or Medicaid, nor to work for free. We do so because nonprofit hospitals are where most of our jobs are, and because (like you said) many of us feel an obligation to take care of indigent patients.
I’m just pointing out that there are other options.
You are right – EMTALA does not force us to take Medicaid, but it does require we treat all patients including them (as well as the uninsured) – with at least stabilising treatments. Thus we are forced to accept the payment Medicaid provides (I guess we could chose to take nothing however) when we see one of those patients. If we work in an ER (which I would consider the whole point of training in Emergency Medicine) that falls under EMTALA’s law (which I guess these free stading “ER’s” you describe get out of that), we have to see everyone. That is not fair – since no other doc’s are forced to provide uncompenstated care based upon their speciality choice alone (I guess we will agree to disagree on what constitutes practising Emergency Medicine, however).
My mom is in the hospital. She is in the crapiest hospital in the world! How can she transfer hospitals without the doctors release and still get the insurance to pay?
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