Nonemergent Complaints and Refusal of Care


A few recent emergency department complaints:

1. “My husband is snoring too loud when he sleeps.” Husband shrugs his shoulders.
2. Nonverbal patient sent from nursing home for evaluation of “irregular heart rate.” History on the transfer papers includes chronic atrial fibrillation … which causes an irregular heart rate.
3. Patient sent by another physician for immediate surgical consultation to rule out necrotizing fasciitis. Physical exam had a 1 cm boil on the hand with a small amount of lymphangitis.

In retrospect, all of the complaints seem like relative non-emergencies.

Prospectively, how many of the visits would have been “nonemergent” to an average layperson?

How many of the visits would have been denied payment by the new Washington State law?

How many of the visits would have been augmented by additional findings to make the complaints more serious if the patients and physicians knew that they wouldn’t otherwise be paid for the visits?

1. Further history states that husband sometimes has apnea during his sleep. Physical examination shows he is overweight. Workup for acute exacerbation of “obesity hypoventilation syndrome“.
2. Call to the nursing home confirms that patient was moaning most of the day and that his heart rate was faster. Pressing on the patient’s chest causes her to moan. Patient worked up and admitted for chest pain and cardiac arrhythmia.
3. The patient is admitted for IV antibiotics because of the possibility of necrotizing fasciitis. Lymphangitis alone can be an admissible diagnosis.

So three patient presentations which would likely need little evaluation and could all be reasonably treated on an outpatient basis are also just as easily able to be classified as admissible diagnoses by highlighting certain aspects of the patient’s history and physical examination.

Washington State doesn’t want to pay for first degree burns? There looks like a small blister in the burn. That makes it a partial thickness burn. Let’s debride it. Increased costs.
Washington State doesn’t want to pay for pregnancy screenings? I’m betting that the women who want to be screened will now all have abdominal pain. Urinalysis. Pelvic exam. Ultrasound for those with positive pregnancy test. Costs increase significantly over a routine pregnancy test.
Washington State doesn’t want to pay for “chronic tonsillitis”? Patients will state that their tonsils just started hurting a couple of days ago. Strep test. Maybe a CBC and a monospot. Costs increase.

When governments pay for certain outcomes and not for others, the governments are guaranteed to get the outcomes they pay for.

While some may assert that it is inappropriate to emphasize points in a patient’s history to make complaints seem worse, the fact is that workups are largely subjective and dependent on a physician’s risk tolerance. Some physicians, even most physicians, may say that a patient with a boil and minor lymphangitis may be treated as an outpatient with oral antibiotics. A small subset of the people treated as outpatients will get worse and likely have bad outcomes. The findings are likely MRSA and MRSA kills more than 30,000 people each year. Those providers who want to be extra thorough or who want to minimize the risks of patients having a bad outcome may do “extra” workups that are still medically appropriate.

Abuse of emergency services needs to be addressed, but cutting payment for nonemergency services when there is no disincentive to obtaining more costly services will only increase the demand for the more costly services. It’s all about the Benjamins.

Emergency care is about to become a bigger drag on Washington’s budget. Just watch.




  1. If you could somehow safely identify at triage and defer care on the 20% of ED patients who would otherwise receive the least amount of care in the ED, you would save less than 4% of the cost of care for all the patients treated in the ED, and less than 0.012% of the cost of all care provided in the US. All this bruhaha about unnecessary ED visits is a distraction from the real opportunities for reducing unnecessary costs in our health care system:

    Fickle Finger

  2. It’s true that the government gets the outcome they pay for. Unfortunately, people in general don’t understand this, but they believe in the magic of “O’care” as if it guarantees them no sickness, no mishaps at all in life. And therein lies the bigger rub.

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