Misuse of Triage Category to target ED co-payments

Unless you’ve been hiding under a very large rock for the past month or, like me, tend to catch the news only in brief snippets via the internet, you are most likely aware of the 31 March release of the National Commission of Audit  report. This is essentially a collection of reviews and recommendations made by a government appointed think-tank on wide-ranging issues affecting the ongoing management of Australia as a nation, with a heavy emphasis on economics, models of federal / state government funding and co-ordination, and with a particular focus on expenditure constraints.

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The report(s) can be found at:   http://www.ncoa.gov.au/

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Health care expenditure and options to contain it are one of the areas addressed in some detail in the report. The relevant sections are 7.3 (healthcare in general) and 7.4 (the PBS) and can be found here:  http://www.ncoa.gov.au/report/phase-one/part-b/7-3-a-pathway-to-reforming-health-care.html

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One widely publicised recommendation is the introduction of a co-payment of $15 for patients seeing a GP. Measures would be introduced to prevent GPs from waiving or circumventing this. This has been enthusiastically criticised by the AMA and RACGP, and will not be discussed further here.

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A second recommendation, perhaps not so widely known as yet, is the introduction of a co-payment for patients attending public hospital Emergency Departments (EDs). No exact figure has been attached to this in the report, however it is recommended that this co-payment should be “…at levels higher than those proposed for out-of-hospital-services.”

 

This recommendation, by itself, is concerning enough. However, the report goes on to suggest the manner in which we should select which patients are liable for an ED co-payment, and which patients should be seen for free. The recommended discriminator is the Australasian Triage Scale (ATS) category assigned to the patient:  Category 1, 2 & 3 patients should be seen without charge, while category 4 & 5 patients should be liable for the co-payment. The stated aim of this approach is to charge those patients who could have seen their GP instead of presenting to ED (and specifically, to discourage patients who might “inappropriately” avoid seeing a GP and paying the new GP co-payment, from turning up to a free ED instead).

The relevant section of the report is quoted verbatim below for your reading pleasure:

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“By introducing co-payments for services that are currently covered by bulk billing there is a risk of cost shifting, as some patients may seek out free treatment in the emergency room of public hospitals for services that would more appropriately be treated by a general practitioner. To address this issue, State governments should consider introducing equivalent co-payments for certain emergency room settings.

A possible co-payment structure for emergency rooms could be based on the hospital triage categorisation system. Emergency room patients are currently triaged on the basis of the speed with which they need medical attention. Triage categories one, two and three relate to patients who present with critical, life-threatening or potentially life threatening conditions. Co-payment arrangements would not apply in these cases.

Triage categories four and five relate to less urgent conditions that in many cases could be more effectively treated in a General Practitioner setting. State governments could consider introducing co‑payments for triage categories four and five, at levels higher than those proposed for out-of-hospital services.

A payment structure along these lines would retain free emergency room care for those in genuine need while providing price signals that direct patients to access the most cost effective treatment setting.

There would also be a need to ensure that the co-payment provides a price signal as actually intended. In this light, consumers would not be able to insure against the co-payment. Similarly, medical practitioners who wish to bulk bill should not be able to waive the co‑payment. The Government will need to ensure the co-operation and compliance of insurers and doctors in the implementation of these arrangements.“

While the wider ethical issue of charging Australian ED patients anything to access what is meant to be free universal healthcare is certainly worth addressing, it is fodder for another time. Here, I wish to examine more specifically the proposed use of the ATS as a dichotomising tool for deciding which patients should have to pay. The ATS was never designed, nor validated, as a tool for defining which patients have “GP” versus “ED” presentations. Its role is purely to sort people based on the urgency with which they should receive full assessment and treatment, in the context of the perceived likely time-course of any threat to life, limb or health. The Australasian College for Emergency Medicine (ACEM) guidelines on the implementation of the ATS open with:

“Triage is an essential function in emergency departments (EDs), where many patients may present simultaneously. It aims to ensure that patients are treated in the order of their clinical urgency which refers to the need for time-critical intervention. Clinical urgency is not synonymous with complexity or severity.“

(https://www.acem.org.au/getattachment/d19d5ad3-e1f4-4e4f-bf83-7e09cae27d76/G24-Implementation-of-the-Australasian-Triage-Scal.aspx)

The second sentence, above, cannot be stressed enough. While this statement is self-evident to any emergency medicine clinician, the layperson’s understanding of the ATS lends itself to the incorrect conclusion that a lower triage category equates to “less severe” or “perhaps doesn’t need to be at the hospital”. Unfortunately, in a political climate of seemingly intentional misunderstanding of the factors that impede efficient function of an ED, the government’s ongoing obsession with the idea that large numbers of “GP” patients somehow account for the majority of ED overcrowding, long waiting times and poorer patient outcomes, makes it all too easy to latch on to what superficially appears to the uninformed to be a simple and ready metric of who is, and is not, a bona fide ED patient. It is unfortunate that those in a position to formulate, and potentially implement, policy in such matters lack the subject matter expertise (or the willingness to seek appropriate expert advice) to enable them to make properly informed decisions.

So, let us suppose that the Commission of Audit recommendations are adopted as policy, and we are instructed to extract a co-payment of as yet undetermined magnitude from every ATS Cat 4 & 5 patient presenting to ED. The goal is to discourage inappropriate use of ED, and in a perfect system, to charge only those patients who present to ED when they could reasonably be expected to have sought medical care from a GP instead. One might wonder, of all the Cat 4 & 5 patients presenting to a typical Australian tertiary ED, how many of them could have, or should have, gone to their GP instead? This is inherently a quite subjective clinical judgement call, but we could probably agree on a couple of overarching ground rules without too much dissent. Firstly, on what basis do we decide whether the patient should reasonably have thought they required the services of an ED? Wielding the hugely informative power of the retrospectoscope is grossly unfair; we cannot use the final diagnosis, or disposition, to decide who needed to be in ED. The patient and, indeed, the triage nurse have only the patient’s presenting complaint, their symptoms, to go on, and this is a more fair and robust starting point.

Raven et al. took an interest in the disparity or non-predictive relationship between presenting complaint and final diagnosis and disposition in some 34,942 ED patients, publishing their work in JAMA in 2013. Among their findings, only 6% of patients (across all triage categories) were deemed “GP patients” despite their presenting complaints being shared by some 88% of all ED patients, including those requiring admission and/or urgent intervention. The take home point here is that there is exceptionally poor concordance between the patient’s presenting complaint, and their final diagnosis. Therefore, using their final diagnosis to retrospectively determine whether they should have come to ED in the first place is not a tenable or sensible way to discriminate between “GP” and “ED” patients and, by extension, who should be billed for a co-payment.

So, if we are going to try to filter out the “GP” patients, we should do it based on the information available at triage, with no knowledge of their future clinical journey or ultimate diagnosis. In the spirit of scientific inquiry, I have reviewed the triage information (and only the triage information) for every ATS Cat 4 and Cat 5 patient presenting to TCH ED over a single 24 hour period (midnight to midnight) on a weekday in 2014. Based on the recorded triage information (age, presenting complaint, triage nursing note) I have made an admittedly subjective (but clinically and experientially reasonably informed) decision as to whether each of those patients could reasonably have sought assistance from their GP, or whether presentation at ED was appropriate. This judgement was made without consideration of their final outcome, or the fact that their presenting complaint was unlikely to represent a diagnosis requiring hospital resources. If it was something that could herald important pathology or require intervention, and could not be reasonably discerned by a layperson as being safe / non-urgent, then I put it in the “appropriate for ED” bucket (e.g. abdominal pain in a child, acute mental health presentations, chest pain). Complaints that frequently present to ED, but could easily be managed in the community (e.g. minor peripheral trauma that happened 2 or 3 days ago that may need an xray), and chronic complaints with no real acute component were tossed in the “GP” bucket. *

Preliminary results:

• n = 125 patients (all Cat 4 & 5 presentations for a 24 hour period on a weekday)
• 58 % presented to ED between 0800-1600hrs, 42 % “after-hours”
• 29 % had presentations I deemed could be reasonably managed via their GP
• 71 % had presentations I deemed required ED assessment +/- management
• 67 % of “GP” patients presented during business hours of 0800-1600hrs
• 33 % of “GP” patients presented outside of those hours

* Clearly there are huge limitations on any conclusions drawn from this data. Defining rigid criteria by which one can categorise “GP” versus “ED” patients is fraught with difficulty. In an effort to iron out the difference in clinical gestalt in making such assessments, my intention is to recruit a number of FACEMs, and a number of GPs to independently review the same data sets, and pool their responses (calculating kappa values of inter-observer variability) and examining the results. While there will be some variability, I suspect it is highly unlikely that such an analysis would not find that the overwhelming majority of Cat 4 & 5 patients (71% in my limited analysis) are not “GP” patients.

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Thus, even if one accepts that we should be charging “GP” patients to use ED resources, if we are forced to implement a co-payment using the inappropriate tool of the ATS as a discriminator, we will  almost certainly be inappropriately billing the vast majority of patients who are required to pay the fee.