When patients arrive at the emergency department of Indian River Medical Center, they are assessed by a medical team to determine the urgency of the illness or injury. Patients also provide financial and insurance information. For those patients who are medically indigent and arrive with a non-emergency, what is not assessed is a copay.

In other words, if someone with little or no income and no insurance shows up at the ER for treatment of a non-emergency condition, they are not required to pay for treatment. Instead, the county’s Hospital District – which exists to provide medical care to indigent residents of the county – reimburses IRMC for any expenses.

That policy appears on the verge of changing. In the hopes of thinning out the seemingly eternal ER logjam, hospital officials are considering charging a fee to those people who up till now have been treated for free.

The hope is that a copay would discourage medically indigent people with non-emergency issues from heading straight to the hospital when they would be better treated by a primary care physician in a clinic.

The size of the copay discussed at the May hospital finance committee meeting where the subject first came up, and later at a meeting of the Hospital District board, was $50 to $60 per visit.

“I don’t object,” said District Trustee Allen Jones, who also sits on the hospital’s finance committee. He told his fellow District Board trustees that the hospital’s interim CEO Karen Davis had brought the subject up and asked for the District’s opinion.

“The ER is not designed for primary care,” said Jones. “It’s clogging up the emergency room. Certainly, those doctors and nurses want to take care of anybody who comes in. But the priority has to be emergencies.”

Jones believes a copay would put the ER option on an equal footing with other lower-cost agencies, including Treasure Coast Community Health Care, the Health Department and Whole Family Health Center, all of which also receive District funding for indigent care. All charge a co-pay, though it can be as low as $10 and enforcement can be lax.

“If you go to Treasure Coast Health, they’re going to try to collect some money from you,” Jones said. “If the ER says ‘No, we’re not going to ask you for money,’ that makes it pretty simple” for a patient without money to decide where to go.

That theory struck a chord with nearly all the District trustees, none more emphatically than Karen Deigl, CEO of the county’s Council on Aging.

“The reason people are going [to the ER] is because it’s free,” said Deigl.  “If we start putting a charge on them, they’re going to start going to Treasure Coast, the Health Department, the VNA bus. We just need to put a charge there – 50 bucks, that’s it.”

“Then you have to go fund those places,” said trustee Ann Marie McCrystal, a retired registered nurse. She thinks the outflow from the ER would lead to an influx at other locations and create another issue for the District.

It wasn’t clear whether Davis’ suggestion includes after-hours trips to the ER, when indigent patients – like anyone else – are worried or suffering but have few options available for lower acuity care.

“The thing we don’t want is for people to feel it’s a penalty for being in the position they are in,” said Ann Marie Suriano, executive director of the Hospital District. “That is not the intent.”

She urged the board to work collaboratively with the hospital to “do some communication that feels right for the patient, ahead of time, that effective on ‘x’ date, this is going to come into play. This is important so that they receive the best care.”

“Best care” is a constant refrain as hospitals try to change habits that drive lower-income patients to use the ER as a family doctor’s office. Because of changing shifts at the ER, patients often are seen by different practitioners on different visits – doctors and nurses not familiar with their medical histories –  in contrast to a primary care clinic, where a doctor or nurse frequently has seen the patient before.

Currently, a District-funded initiative has a team of navigators in the ER trying to educate patients on their options beyond the pricey and less personalized care of the ER. How effective that program is has proven difficult to assess.

Jones pointed to a document presented at the finance committee meeting by hospital CFO George Eighmy that showed District-covered indigent ER reimbursement fell slightly – by 1 percent – in the five-year span ending in 2017. The drop appears to be continuing in 2018 and is projected to fall another 10 percent in 2019.

“We gave credit for that principally to Obamacare,” Jones said. “People presented at the ER, but they had insurance where they didn’t have it before.”

As the District Board and hospital consider imposing an ER copay on the poor seeking non-emergency care, the Hospital District is simultaneously thinking about offering help to more people.

At Jones’ request, District staff has spent six weeks researching the benefits and consequences of enlarging the pool of patients it covers.

That would come by raising the income ceiling for medical indigency from 150 percent of the federal poverty guidelines to 200 percent.

A free-wheeling, wide-ranging discussion of the possible change that took place at the District’s chairman’s meeting in mid-May was tabled until the merger with Cleveland Clinic is in place.

That is so the District Board knows exactly where it stands in terms of charity care coverage at the hospital before making any police changes.

Cleveland has said if it acquires IRMC, the hospital will follow the guidelines for its Florida division, but those guidelines, slightly different from those of its Ohio hospitals’ policy, were still being clarified, according to trustees. 

So far, negotiations have not yet begun on a definitive agreement for the Cleveland Clinic acquisition of IRMC, though hospital officials continue to say it is expected in early July.