Midland Memorial Hospital has invested in patient-friendly services that are directing non-urgent ED patients to the most appropriate care setting.


To decrease inappropriate emergency department (ED) use, Midland Memorial Hospital, serving Midland County, Texas, introduced a telephone triage system in 2009. The free service allows county residents access to medical advice from a registered nurse (RN) about whether a medical situation justifies an ED visit. Patients who arrive at the ED and do not need emergency care—often referred to as non-emergent patients—are given the option of seeking treatment in a less costly setting, such as the nearby urgent care center, or paying $150 before they are treated in the ED.

By promoting suitable alternatives to ED use, Midland Memorial Hospital is successfully redirecting non-emergent patients to more appropriate care options and dramatically improving ED throughput. A bonus: The hospital’s bad debt fell by more than $3 million in the first year as a result of the initiative. 

Meanwhile, patients who need emergency treatment are being seen much more quickly, and those who do not are saving money. “We don’t collect a lot of those $150 copays or deposits for care in the ED,” says Midland Memorial CFO Stephen Bowerman. “People would prefer to be treated at the urgent care center at half the cost.” 

Following a Trend

Midland Memorial is one of many hospitals that are charging upfront fees to reduce ED crowding. Indeed, HFMA’s Richard L. Gundling, FHFMA, CMA, vice president of healthcare financial practices, says at least half of all hospitals are now charging up-front fees for non-emergent care and collecting deductibles and copayments at the time of service.

Of the more than 6 million ED visits to HCA hospitals in 2011, about 314,000 were screened by a clinician and determined not to have an emergent condition. Advised of their options, about 80,000 chose to seek an alternative setting while about 233,000 remained in the ED for treatment and paid an up-front fee—typically between $100 and $150—to do so, says Ed Fishbough, a director for HCA.

“It has been a successful part of helping to reduce crowding in emergency departments and to encourage appropriate use of scarce resources,” Fishbough says. “This helps ensure that the sickest patients get treated quickly and that those who do not have an emergency have access to more efficient, less costly care settings.”

For HCA, up-front fees for non-emergent patients visiting the ED started in a Houston hospital in 2004. Although the practice has spread to other HCA facilities, fewer than half of its hospitals currently charge upfront fees. Of those that do, each hospital sets the fee.

Pregnant women, children under age 5, and patients who are 65 and older are excluded from HCA’s up-front-fee policy. In addition, clinicians can decide to exclude non-emergent patients from the policy on a case-by-case basis. Typically, two caregivers—for example, a triage nurse and a physician—make a determination about whether to waive the upfront fee in a specific situation.

Helping Patients Find Needed Care

Up-front fees may have a potential downside, warn some experts: Uninsured patients who truly need emergency care may fear going to the ED because they worry that they will be asked to pay on arrival.

Midland Memorial is avoiding that repercussion with its telephone triage system, which directs patients to the best place to seek care. The telephone nurse triage system allows individuals to discuss their symptoms with a registered nurse (RN), who advises them on the proper setting for treatment. The nurses use a proprietary software program, developed by a vendor. It prompts them to ask callers a series of questions about their symptoms and uses algorithms to help the nurses make one of five recommendations:

  • Proceed to the ED.
  • Make an appointment with a primary care physician.
  • Go to an urgent care center.
  • Seek treatment at a federally qualified health clinic.
  • Treat symptoms at home.

The phone line, staffed by RNs hired by Midland Memorial, operates around-the-clock 365 days a year. Typically, a single RN staffs the triage line. However, in the three years since it was implemented, Memorial Midland has identified certain time periods in which call volume is heavy, and a second nurse is added during those periods.

Maintaining the telephone triage system costs about $500,000 a year, Bowerman says. That includes the salary and other staff costs as well as the software (i.e., the computerized protocols) that helps the nurses evaluate patients’ symptoms.

In January 2012, Medical Center Hospital in Odessa, Texas, began partnering with Midland Memorial on the nurse triage line. The two hospitals now split the costs and are working to grow the triage line into a regional service.

Screening Patients in the ED

In compliance with Emergency Medical Treatment and Active Labor Act, Midland Memorial does not discuss potential ED fees with patients until after they are examined. When patients present at the ED, they are screened for any emergency medical conditions by a physician. If a patient requires emergency care, treatment proceeds.

If emergency treatment is not necessary, a member of the registration staff comes into the room to notify the patient about the physician’s determination and to gather insurance information. Patients who do not have insurance are asked to pay $150 before treatment continues or to seek treatment at another setting.

These ED screening exams identify between 200 and 300 patients a month—about 5 percent to 7 percent of those who arrive at the ED—that would be more appropriately treated elsewhere.

“We have access to the schedule of our urgent care center in town, so we can schedule patients there. It’s much cheaper than $150, and we can usually get patients in within 24 hours,” Bowerman says. “If they need assistance in making an appointment at the federally qualified health clinic, we will assist them with that.”

Making It Work

Midland Memorial’s introduction of upfront ED fees has been successful, Bowerman says, because the nurse hotline was introduced at the same time. The approach has contributed to improved performance on several important measures:

  • A 24 percent reduction in lower-acuity ED patients
  • A decrease in bad debt from $8.1 million in 2008 to $5.5 million in 2009
  • A reduction in the left-without-being-seen rate from 4.9 percent in 2007 to 1.7 percent currently
  • A 40-minute decrease in door-to-doctor time (the time it takes an ED patient to see a physician)—from 67 minutes in 2007 to 27 minutes in 2012
  • Shorter decision-to-admit times (the time from when a physician decides to admit an ED patient until the patient is in an inpatient bed)—from 158 minutes in 2007 to 84 minutes in 2012
  • A 35-minute decrease in total ED length of stay (including for patients who are discharged), from 248 minutes in 2007 to 213 minutes in 2012

Bowerman credits the nurse hotline for Midland Memorial’s relatively smooth transition. “It was a dramatic change for people who felt they needed to come into the emergency department,” he says. “The telephone nurse triage was helpful because it gives people an avenue to seek before they show up in the emergency department and spend a couple hours going through the medical screening exam process—only to be classified as non-emergent.” 

Here are some other tips for success from Midland Memorial:

Heavily market the nurse triage line. The half-million dollar cost of the nurse triage line is a fixed cost no matter how many calls are taken, Bowerman says, “So we want people to use that line.” In addition to radio ads and billboards, Midland Memorial sought publicity in the local media and advertised the service in its ED. Midland Memorial educated primary care physicians and the staff at the nearby federally qualified health clinic about the nurse hotline and asked them to encourage patients to use it. The hospital also sent refrigerator magnets to all residents in the mail and promoted the triage line with a flier in English and Spanish.

 Midland Triage Flier

All the promotion has paid off. Within the first year, call volume for the nurse hotline grew by about 1,500 calls—from an average of 2,000 to 2,500 calls per month to between 3,500 and 4,000 calls. 

Seek early support from ED physicians. Before introducing the ED medical screen exam and up-front fees, gain buy-in from ED staff on funneling patients to the proper care settings. At Midland Memorial, an independent company employs and manages the ED physician staff. “We probably would not have done this had we not had their support from the beginning and their participation as we developed the process,” Bowerman says.

Lawrence Wilson, MD, the hospital’s medical director of emergency medicine and hospitalist services, says implementing the upfront collection policy had minimal impact on the emergency physicians other than the requirement of performing medical screening exams so that non-emergent patients can be referred to other sites of care. Although the policy does speed ED throughput for patients who need emergency treatment, ED volume continues to increase, and some patients continue to rely on the ED for primary care. “Importantly, we are helping make our patient population aware of the alternative routes to primary care,” Wilson says. “Nevertheless, when the availability of primary care is a challenge for many of our patients, we are still serving the role of safety net.”

The biggest beneficiaries of Midland Memorial’s approach are patients who need emergency care. “The patients who have emergent needs certainly appreciate this new program because they know our emergency department physicians’ attentions aren’t diverted by other cases that don’t require immediate care,” Bowerman says. 


Lola Butcher is a freelance writer and editor based in Missouri.

Quoted in this article (in order of appearance):


Stephen Bowerman, CFO, Midland Memorial Hospital, Midland, Texas, is a member of HFMA’s Lone Star Chapter (stephen.bowerman@midland-memorial.com).

Richard L. Gundling, FHFMA, CMA, vice president of healthcare financial practices, HFMA, Washington D.C. (rgundling@hfma.org).

Ed Fishbough, a director, HCA, Nashville, Tenn. (Ed.Fishbough@HCAHealthcare.com).

Lawrence Wilson, MD, medical director of emergency medicine and hospitalist services, Midland Memorial Hospital, Midland, Texas.

Publication Date: Wednesday, January 23, 2013