$5 fee.

[Guest dogeatdog12]

Hi

how does everyone feel about the five dollar patient fee at the emergency room? how do you feel about it? does it work in other countries?

[Guest aneliz]

Pretty hard to enforce....with the drunk that the police bring in...or the suicide attempt....and adds an extra layer of bureaucray that would have to collect it... this would probably COST more than would be gained!

[Guest weerdo]

It would never work. Who would enforce it? The emergency clerk?, the paramedics?, the nurses?. To many variables I think. Anyway, whether or not you think of it like this, that is a two tiered medical system.

[Guest Steve U of T]

If they check your health card (which they presumably do at some point), they can send you a bill in the mail.

[Guest Ollie]

As Aneliz mentioned, the cost in sending people a bill and then trying to collect from them would outweigh the revenue taken in. And who is going to enforce payment? Most people wouldn't be too concerned about having an outstanding $5 payment on their record. I don't think this would fly.

[Guest K2Optimist]

Think about this: if you could go to the store and get a bottle of Pepsi for free every day, would you? Probably. Even if you weren't thirsty, hey, why not, it's free?!

 

Okay, if you have a sore throat at 2 o'clock in the morning, do you go to the emergency room or wait to see your family doctor the following morning? Both options are "free" to Joe Canadian, so why not go to the emergency room and get it taken care of right away! How convenient!

 

Right now there is no "value" to our health care system. Everything is "free". Actually, no ... Joe Canadian thinks we are taxed to heck for health care, so why not get the most out of it??

 

We don't go to the dentist every month because it is expensive. There is a cost involved that most of us cannot afford to go every month. So we budget ourselves and go every 6 months or every year. Health care in Canada has no such "cost" therefore we feel entitled to use it as much as possible. Only when there is a direct cost involved, even $5 per visit, will we see more disciplined use of our health care.

 

Just my 2 cents.

K2O

[Guest Ollie]

K2O,

 

I really don't think that you are describing the average Canadian's attitude towards healthcare. Sure there are people that abuse the system, but I think that the majority are aware of the cost of the system, and how to use it wisely. User fees, even ones that seem insignificant to most people, are a barrier for those on a fixed income. They may decide not to have an illness or injury looked at, and then it becomes worse and ends up costing us more in the long run. We do need to change the status quo, but I don't think that flat user fees are part of the answer.

 

And going to the dentist every month? Whhaaat? Who would do that even if they could afford it? It's totally unnecessary unless you have serious dental issues, and we would need 6x as many dentists to see all those people.

[Guest drews97]

I personally think that the $5 charge could help to cut down reckless use of emergency resources but, like others have mentioned, it would be difficult, if not impossible, to enforce.

 

And Ollie, I have to disagree that the majority of Canadians associate a cost with health care system and use it wisely all the time. I am currently spending 2 months at a rural emergency room in Alberta and, believe me, a fair percentage of people come to the ER with nothing more than cold sympoms that have persisted for less than a couple days. Many people too lazy to make an appointment with their family doc, or who don't want to wait to be seen, simply use the emergency room for little more than a check-up. In fact, often times a mom will bring all her kids in at once saying they all have nebulous symptoms like "a runny nose". People must obviously not be afraid to use the emergency room, but I feel that, in the absence of the availability of a walk in clinic, many people will gravitate to an ER for many lesser problems. Ironically, in the cities the sheer length of time that someone with a minor problem has to wait to see a doctor is a deterrent for seeing a doctor. If you have to wait 3 hours to get your sore throat looked at you'll probably just make an appointment. However, in a rural setting like the one I'm in access to a doctor is much faster so the individual with the same sore throat is more likely to come in.

[Guest marbledust]

There are people that abuse Emergency Departments, without a doubt. But the problem is systemic. Nearly everything I read about the waiting times and backlogs in Calgary emergency departments mentions that many people use it because they don't have access to family doctors, which as we all know well is a problem across the country. Its also a problem for people who don't have access to psychiatrists or other mental health professional - they often reach a point where their only option is to go to Emergency.

 

$5 fee isn't going to dissuade most people for most of the reasons mentioned above. I know in Calgary there has been numerous efforts to educate people on when it is appropriate to use Emergency, none of which I think have been overly successful. There have been other attempts such as a 24 hour health centre downtown, capable of taking care of most medical issues, and a telehealth system. Instead of a meaningless fee, the key is to educate and redirect people towards more appropriate resources. And somehow massively increasing the number of family doctors. Just my humble two cents

[Guest K2Optimist]

What about for those people who choose to get several "second opinions"? If you don't like what the ER doc has to say and/or get the prescription you "want" - why not go to the walk in clinic and/or your family physician and/or another doctor. Currently there are no checks and balances to prevent over-use of the system.

 

And, BTW, the once a month dentist analogy is not unlike going to the ER for a runny nose ... both scenarios seem rather unneccesary :eek

[Guest dogeatdog12]

I heard that sweden has implemented the 5 dollar fee but I can't find the studies anywhere?

 

I would hate a $5 dollar prevent someone with flu-like symptoms of HIV not to enter an emergency room. However, this practice does encourage abuse.

[Guest UTMed07]

I think it is fair to ask -- Who is going to most effected by a $5 fee?

 

I don't think it would dissuade people much that have a higher socio-economic status and evidence from Manitoba (CMAJ • January 20, 2004; 170 (2)) suggests universal comprehensive insurance encourage does not encourage unnecessary use:

 

Most people use little health care; high-cost users are a small group of very sick people drawn from all neighbourhoods and all income groups. People living in areas with low average household incomes use fewer physician services [emphasis added] than might be expected, despite their poor health status.

 

Since the high-cost users are few it would make most sense to target the education to the people visiting the ER--eg. make sure they know about about Telehealth.

[Guest aneliz]

Yes there are abuses of ER's... but most Joe Canadians that have a family doctor think to themselves: "hmmmm....sore throat at 2 AM, could go an sit for 7 hours in emerg with lots of drunks, screaming kids, and other sick people and see some random doctor I've never met before OR I could wait until 9 AM and go see my family doctor in a nice clean, quiet office." Not a tough choice....both choices get you seen at ~9 AM...one allows you to sleep for the night....

 

But not everybody that goes to emerg with a 'minor' complaint that could be dealt with by a family doctor is necessarily abusing emerg. If you have a family doctor and you decide to go to emerg because you have a bit of a sore throat that has lasted 3 weeks...that is an abuse of emerg.

 

However, if you have no family doctor and you go to emerg because you have had a sore throat for three weeks....that might be different.

 

Same presenting complaint but different 'abuse of emerg' potential.

 

Does the one without the family doctor deserve to be charged a premium for health care because they don't have (and can't get) a family doctor?

 

Quite honestly, people don't show up in emerg for a little scratch that they think 'hey, its free, I'll go check that out'. Those with a family doc will go there over emerg any day and those that don't have one will usually wait, for months, until they just can't stand it anymore and then show up in emerg. When something that could have been treated easily months ago is now a bigger and more difficult to solve problem.

 

Meanwhile, if you want to talk about abuses of the system, some people with a family doctor are there almost weekly (because it is free) because they noticed a small bump on their arm (bug bite) and they had two normal bowel movements rather than one yesterday....

 

I don't think charging people for using emerg is the answer.

[Guest leviathan]

People complain about lack of family doctors, however I feel that this is not an issue. I don't know how it is in your neck of the woods, but in Greater Vancouver, there are walk-in family practice clinics on every street corner for anyone who needs to see a doc.

 

In regards to the $5 fee, has anyone tried to see it from the flip side? What if instilling this fee only caused people to think it was alright to visit the ER, because there is now a service fee in place to cover the less emergent treatments?

[Guest aneliz]

There may be walk in clinics around - and they are fine if you have a sore throat, a UTI, a cough, etc (some acute, easily solved, requires minimum follow-up problem). However, they have long line ups, are only open limited hours (6-9 PM) and are designed to cover the practices of the family docs that they are associated with after hours rather than serve the masses without a family doctor. They are often full and people are often turned away from them...if you are not 'on the list' by about 6:10, you aren't going to get seen that night...and there is always a line up before they open to try and make it 'on the list' before they stop registering patients for the night.

 

And, there are lots of 'routine' services that the walkin clinic won't do: they don't do paps, they won't do vaccinations, they don't do prenatal care, they refuse to prescribe narcotics and they are a really bad place to try and have a chronic illness managed from (IBD, RA, diabetes, etc)...sure they will refer people to specialists, but then there is no family doc to follow up with....so these people end up seeing a different doctor at a walkin clinic every time, getting less than co-ordinated care and are trying to manage their health on their own. That is a problem that no walkin clinic can fix. So, sorry, but the lack of family doctors IS a problem.

[Guest marbledust]

they have long line ups, are only open limited hours (6-9 PM) and are designed to cover the practices of the family docs that they are associated with after hours rather than serve the masses without a family doctor.

 

Is this the model in Ontario? In Calgary there are many walk-in clinics that are opened all day/evening and on the weekends. They are not associated with family doctors who have private practices, but are staffed by mainly by doctors who concentrate on doing "walk-ins".

 

The do serve a good purpose, however they are far from a substitute to having a family doctor. The waits are often horrendous, the doctors don't know your history, and the level of care (speaking from experience) is often subpar. There are a number of reasons the care is subpar, so I am not criticising the doctors who work there. In addition, as mentioned by another poster, they can often only deal with minor problems and procedures. Even getting a perscription can be difficult, again because of a lack of a previous relationship between the doctor and patient. If you use the clinics repeatedly, it is probable that you will be seeing a diffrent doc each time. This also has implications if you need any sort of follow up.

 

The bottom line is you can't depend on walk-in clinics as your primary health care provider. This is especially true if you have an chronic problems, children, eldery family members.

[Guest leviathan]

they have long line ups, are only open limited hours (6-9 PM) and are designed to cover the practices of the family docs that they are associated with after hours rather than serve the masses without a family doctor.

 

Again, as the last person said, that is not the case in Vancouver. Most, if not all clinics are open 9am-9pm Monday-Friday and usually shorter hours on the weekends, sometimes closed on Sunday. I agree with you about the lack of care, but I don't think they'll get any better treatment for chronic conditions or vaccinations if they are going to the ER. They will, however, get treatment for that sore throat, or that nagging cough, or whatever treatment they would otherwise go to the ER for, which was the crux of the argument that you have strayed away from.

[Guest marbledust]

Actually it is you Leviathan that seems to be straying from the original argument:

 

People complain about lack of family doctors, however I feel that this is not an issue.

 

The point isn't that people can't recieve care from a walk-in clinic, care that is probably similar in most cases to what they might get in emergency. It is that the lack of family doctors that causes people to depend on emergency and walkin clinics, neither of which is a desirable option. If you don't have a family doctor, a $5 isn't going to solve the problem. Nor is having more walk-in clinics.

 

Obviously the easily accesible walk-in clinics don't exist everywhere, as the post above shows. You also don't find them in smaller areas.

[Guest Ian Wong]

Walk-in clinics are an extremely inefficient way to get care for anything but the most superficial of health concerns; this is not surprising, since walk-in clinics actually cater to these sorts of easy cases.

 

You are not going to find many walk-in clinics anxious to schedule you for annual mammograms, or to do your regular pap smears. You're not going to find many walk-in doctors willing to counsel you on your depression, or to take the time to call you with abnormal lab results or to visit you when you get admitted to the hospital.

What the walk-in clinics thrive on, is refilling prescriptions (whether those be blood pressure meds or birth control pills), taking a look at your upper respiratory infection, and either sending you back to your family doctor if you've actually got something chronic and difficult to manage, or sending you to your nearest Emergency Department if you've actually got something acute and difficult to manage.

 

The issue with walk-in clinics is that a walk-in patient is usually simple to manage and quick to discharge, while often patients seen in the family practitioner's office have multiple complaints, many of whom may be chronic and take more time to address. Despite this, there's no recognition in the provincial fee schedules for this discrepancy in difficulty and time expenditure in managing these two very different patients; the province pays you the same amount of money.

 

So the walk-in clinic doctor who spends 45 seconds before prescribing you azithromycin for your nagging cough gets paid the same $25 that the family doctor would get for spending 20 minutes struggling to handle your 75-year old female diabetic patient with hypertension, osteoporosis, and Alzheimer's dementia, who has just been diagnosed with atrial fibrilliation and now needs close monitoring for her anti-coagulation medicine.

 

There's a significant amount of tension and resentment among family doctors that walk-in clinics are "skimming off the easy patients", while leaving the more difficult patients for either the family doctors or the Emerg doctors to handle.

 

If there were actually enough family doctors out there practising full-service medicine, then there would be no need for walk-in clinics to exist (you'd just go and get a same-day appointment with your regular family doctor). Then, you'd be getting a physician who's actually familiar with your medical history, knows which medications you are currently taking, and will stay with you to handle your medical problems irrespective of whether they are simple (ie. sore throat), or difficult (ie. depression or management of chronic diseases).

 

I think I'll also move this discussion into the Primary Care forum...

 

Ian

[Guest leviathan]

Actually it is you Leviathan that seems to be straying from the original argument:

 

 

Quote:

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People complain about lack of family doctors, however I feel that this is not an issue.

--------------------------------------------------------------------------------

 

Actually it is evident that you did not comprehend that statement correctly. The lack of family doctors is not an issue with ER problems, I never said anything about walk-in clinics replacing family physicians. It is obvious and everyone knows that the walk-in clinics cannot replace family physicians. My statement was about walk-in clinics as a means for preventing patients from visiting the ER in the case of not having a family physician.

 

The point isn't that people can't recieve care from a walk-in clinic, care that is probably similar in most cases to what they might get in emergency.

Yes, and this point was already made.

 

It is that the lack of family doctors that causes people to depend on emergency and walkin clinics, neither of which is a desirable option. If you don't have a family doctor, a $5 isn't going to solve the problem. Nor is having more walk-in clinics.

Again, you are straying from the crux of the argument in this thread. The argument is about reducing ER times, not about replacing family physicians.

 

Obviously the easily accesible walk-in clinics don't exist everywhere, as the post above shows. You also don't find them in smaller areas.

I'll give you credit for that...Smaller rural areas are not going to have many, if any walk-in clinics.

[Guest aneliz]

However, they have long line ups, are only open limited hours (6-9 PM) and are designed to cover the practices of the family docs that they are associated with after hours rather than serve the masses without a family doctor. They are often full and people are often turned away from them...if you are not 'on the list' by about 6:10, you aren't going to get seen that night...and there is always a line up before they open to try and make it 'on the list' before they stop registering patients for the night.

 

Yup...that is the model in Ontaio...at least in London and the GTA anyway. They are called "after hours clinics" and they are run by a group of family doctors (either they rotate through it themselves or they pay others to cover it) instead of being 'on-call' for their practice. The clinics are designed to divert people from the practice with minor complaints from the ER. What happens though, is that everyone without a family doctor will show up and try and be seen by the after hours clinic. And they are only open limited hours (6-9 PM on weekdays and full days on weekends). They are designed to treat acute problems that are not severe enough to warrant a trip to emerg - like the kid with the fever, the person with the cough or UTI, etc...not refill prescriptions, do routine care or follow chronic illness. Some have large signs on the wall like: "we will not make referrals to specialists" or "we will not prescribe narcotics" or my personal favourite "we will not prescribe emergency contraception (plan or discuss abortion".

 

They will register patients from the time the doors open at 6 (usually there is already a line waiting for the door to be opened) until they have 'filled' the spots for the night. (They want to be DONE by 9!). The rest of the people that don't make the list are told to go to emerg if they feel that they need treatment.

[Guest marbledust]

I actually understand the argument just fine. However, I don't think you do:

 

The lack of family doctors is not an issue with ER problems

 

There have been exhaustive studies done in Calgary that shows there is a direct corelation between the number of people without family doctors and a dramatic increase in the use of emergency departments. It's a fact. And I am sure that it is probably representative of the situation in other cities. So yes, even if you don't agree, the lack of family doctors contributes significantly to the problems experienced by Emergency Departments.

 

I don't know how it is in your neck of the woods, but in Greater Vancouver, there are walk-in family practice clinics on every street corner for anyone who needs to see a doc.

 

I'm not the only one who has pointed out the issues related to this statement. No need to repeat them again.

 

 

I never said anything about walk-in clinics replacing family physicians. It is obvious and everyone knows that the walk-in clinics cannot replace family physicians. My statement was about walk-in clinics as a means for preventing patients from visiting the ER in the case of not having a family physician.

 

This seems to be a bit in contradiction with your statement above. Calgary is full of walk-in clinics, most of which are open until 11 pm. They haven't taken the pressure off of a system with a growing population and lack of family doctors. Yes they work for some people, but in most cases (anything remotely complicated), they are of limited use. So where do the patients turn? Emergency.

[Guest soapyslicer]

A $5 fee won't slow anyone down, particularly if they are sent a bill. The ambulance service in BC has about a 42% payment rate and it is $55 for a BCer. Many, many people take it simply because they think they will get seen sooner if they come in by ambulance. This of course does not happen and instead of just the patient waiting to be seen you now have a paramedic baby sitting them.

 

I have no idea what the solution is. I can say however that I am glad my nights as a paramedic sitting in the hospital wait room with a very stable pt for 8 hours are over. Now of course I will be on the other side saying why did you guys bring him in? At least I will know the answer - cause he said he want to come!!!:rollin

 

soapy

[Guest UWOMED2005]

My favourite case was seeing a 72 yr old with a relatively minor case of cellulitis, who was brought in by ambulance at his and his wife's insistence.

 

The best part is, his wife followed the ambulance the whole way in her own car. . . and was actually physically in the ER before the patient!