“Gatekeepers” role

A two-year-old child with a rectal temperature of 102°F is brought into the emer­gency department at 2:00 a.m. by his parents because of the fever. He is fussy and is pulling at his left ear.

The patient belongs to a health maintenance organization (HMO) (prepaid health plan). His physician is contacted but refuses permission (refuses to pay) for the child’s treatment.

He suggests that the parents bring the child to the clinic at 9:00 a.m.

This child has the obvious signs of a middle ear infection, which is very painful. However, although it will cause the family a sleepless night, it usually does not progress to any of the possible sequelae (meningitis, mastoiditis, etc.) in seven hours.

It is obvious, though, that the child’s discomfort could be relieved, and the chances of his condition’s worsening could be reduced, by treating him now.

The parents either are not willing or are not able to pay a separate emergency department bill for this visit. Should the physician treat the child?


The hospital has just announced a new policy regarding the treatment of patients who have no insurance.

The emergency physician is now to evaluate patients without insurance in the waiting room, to determine whether they are truly emergent and need formal evaluation in the emergency department.

This would require the emergency physician to talk to the patients briefly in the waiting room and then transfer those who are not emergent to a county hospital.


The emergency physician’s role as gatekeeper in the current atmosphere of cost containment is a very difficult one.

He has to conduct a very complex balancing act, insuring, first, that he does the best for his patient; second, that he does not produce unnecessary financial burdens for patient or family; third, that he complies with hospital administration policies; and fourth, that he protects himself from the risk of malpractice charges.

Even more difficult is the responsibility he has to implement these policies while maintaining a spirit of cooperation among the emergency department staff, hospital administration, medical staff, patient, and family.


In the case of a two-year-old child with significant fever and clinical evidence of a middle ear infection, the case is quite simple.

The child should be treated promptly to relieve discomfort and minimize the risk of complications.

While the parent’s decision to bring the child into the emergency department is implicit evidence that they understand they may be incurring extra costs, the emergency physician should review the situation with the parents to avoid their being able to claim later that they were not properly informed of the potential for additional charges.

At this point, a difficulty may arise when the parents discover that their original estimate of the additional charges was far lower than the amount the physician tells them, and they may refuse treatment for the child.

I believe the physician should strongly encourage the parents to have the child treated, and he should even consider waiving professional charges if this will resolve the situation.

After examining the patient, the emergency physician should contact the HMO physician and, based on his examination of the patient and confirmation of the presence of the clinical condition, the risks, and the patient’s discomfort, request approval for the visit.

The physician can gently remind the parents of the need for them to address these kinds of issues with their HMO because this kind of poor decision making by the HMO primary physician is inappropriate.

Hospital administrators are usually able to understand this situation when the emergency physician carefully explains that if the child suffers a complication and that information is made public, or a law suit is filed against the hospital with subsequent adverse publicity, the money saved by not treating one child is trivial when compared with the losses from adverse publicity and the cost of possible malpractice awards.

Again, the emergency physician should encourage the hospital administration to raise these issues with the HMO.


The second case serves as a good example of the general problem that arises when the hospital administration asks the emergency physician to serve as gatekeeper for all noninsured patients coming to the emergency department.

The request by hospital administrators that the emergency physician examine these patients in the waiting room prior to registration is always fraught with danger.

The physician is faced with the situation in which there is insufficient time, limited opportunity for full history taking and examination, inadequate privacy, and an atmosphere not conducive to optimal interaction between physician and patient.

For certain types of patients it is relatively simple to make this decision in the waiting room.

The problem is that it is difficult to identify this group of patients, and no safe system has been developed to avoid the situation in which a patient with a potentially life-threatening illness or injury will be sent to a county hospital instead of being admitted to the emergency department.

An even more difficult group is the one in which the decision not to admit is based on the assumption that the patient will immediately go to the county hospital for proper evaluation and necessary treatment.

It is impossible to guarantee that the patient will proceed to the county hospital immediately, and thus the physician and the hospital are placed at great risk if patients from this group are excluded from admission to the initial emergency department.

This kind of policy pits the physician against the patient and is often very disruptive to the emergency department.

Many patients do not accept the hospital policy as rea­sonable and berate the emergency department staff for failure to meet expectations. Often the nursing staff is divided on this issue, choosing sides to become advocates of patients or of hospital policy.

Physicians and nurses may provide conflicting interpre­tation of these triage policies to patients, with resultant increased hostility and animosity from the patient toward the institution and the professional staff.

In addition, the physician’s professional income is affected by these kinds of policies. First, the physician may be prevented from providing professional care, and the income, albeit often much less than usual, is lost.

For those patients admitted to the emergency department for a more comprehensive evaluation prior to being referred to the county hospital, the physician now provides significant professional services, yet he is much less likely to be paid because referring these patients to the county hospital makes it quite difficult to justify billing them.

Traditionally, hospitals and physicians have shifted costs in this setting by raising the charges for the paying patients to offset the lack of revenue for the nonpaying patients.

Today, this is far more difficult because of ceilings placed on reimbursement by the paying patients’ insurers and the undesirability of raising professional fees too high, thus discouraging use of the emergency department by paying patients (especially those who have to pay a portion of their care as an out-of-pocket expense).

Hospital administration policies such as these are usually based on a poor under­standing by the administrators of the safety of triage policies.

It is incumbent on the emergency physician group, with support from other medical staff if necessary, to educate administrators as to the hazards and risks of these policies for the individual patient, for the emergency physician and department staff and for the hospital.


I believe that in order to justify the kind of triage policy in which the hospital requires the physician to provide less-than-total evaluation and treatment, he must be able to provide at least minimally decent care.

In other words, the physician must be able to examine the patient in an examining room with nursing and technical staff available as required.

Adequate time must be available for history taking and physical examination. The physician must have discretion to order sufficient diagnostic tests to give him a reasonable amount of confidence that there are no potentially life-threatening conditions.

A reasonable triage policy does not require that every patient be fully evaluated and treated; rather, it demands that the physician have the discretion to obtain sufficient information to make a safe and reasonable decision about the individual patient.

Crucial to such a policy is full documentation of the evaluation and the decision, including a concise summary of the patient’s clinical state at the time of examination.

Also essential is documentation that the patient understands the triage policy and is aware of any recommendations given, including the referral to a county hospital. Finally, attention must be given to the patient’s transportation needs.