Discussion - Private Emergency Departments

It is widely recognised that the Australian government funds and operates a world class public healthcare system, with every Australian being able to access top tier medical care at no personal cost. Yet the system is not without its flaws. An ever expanding metropolitan population and delayed response from the government has resulted in public emergency department resources being stretched to their limits day after day. When previously only certain nights of the week and public holidays would cause a surge in hospital attendances, what is now seen is a perpetual state of endless presentations being recognised as the new standard of business as usual. Ambulance services are also affected with ramping becoming an ongoing issue and now spreading its tendrils into the private hospital system. However unlike the public sector, the private sector has a right to decline to enter into a relationship and offer services to anyone they choose, particularly when their private emergency departments get busy. Should private emergency departments be allowed to turn away eligible patients at the door because they have reached patient capacity?

As the government has introduced tax penalties to a certain portion of higher income earners who do not purchase private health insurance, the number of private health insurance policy holders has increased. Further to this, more and more middle and lower income Australians are recognising the need to look after their bodies with maintenance services such as physiotherapy, chiropractic therapy, and even psychiatric services as stigma around mental illness is slowly being abolished. Accessing these services can be cheaper through private health insurance thus many more policies are being purchased by a wider demographic than ever before. And with this increase has come an increase in the number of people looking to the private healthcare sector for their emergency healthcare.

Recognising an opening in the market share, large healthcare conglomerates such as the St John of God medical group and Ramsay Healthcare have opened up their own private emergency departments promising prompt examination by senior doctors and minimal waiting times at personal monetary expense to the patient. This monetary expense often comes in the form of a flat fee at the front door to see a doctor, with a select list of other services such as laboratory tests and medical imaging being billed to either the patient themselves or their private health insurance provider.

Yet what is not often appreciated by those who purchase private health insurance for the purpose of having the option of attending a private emergency department is that these departments still operate, at the most fundamental level, as a business. Moreover, like any business, and unlike the public hospital system, they have the right to decline to engage in a relationship with certain groups of patients who present at their front door. The most obvious group of patients that may be turned away are those without private health insurance. This does however come with the stipulation that in a life threatening emergency private hospital staff have a duty of care to provide an appropriate level of medical care whilst an ambulance is arranged to transport the patient to a suitable public emergency department.

The second group of patients that may be turned away are those who, in the opinion of an appropriately educated and experienced healthcare provider, will be unable to be definitively managed at the private emergency department and hospital due to unavailable resources. This non exhaustive list of patients may include those with abdominal pain who present when the hospital has no routine surgical cover, and those who present with psychiatric illnesses who may require management by a specialist in a facility not present on the hospital campus.

The third group of patients that are often refused entry to the hospital can be those who present by ambulance. This often group sits out of the public eye, as the private emergency department can enter a state of ‘ring first’ whereby ambulance paramedics are required to contact the medical coordinator prior to arrival to discuss whether or not the patient can be seen at the department. The department is not under any obligation to provide a reason for declining to see the patient, and can remain completely segregated from any liability stemming from medical care of the patient as they remain under the duty of care of paramedics. In the context of the climate described above, what has become common practice is private emergency departments declining to see patients reaching their hospital by ambulance from the community on the basis of their departments being too busy with walk-in patients. It is in my opinion that private emergency departments should not be allowed to turn away patients that arrive by ambulance at their front door when the department reaches capacity.

A situation in which a private emergency department is justified in denying service to someone from the community presenting via ambulance is if their department and waiting room are at such a capacity where any additional persons placed in the same area may compromise structural safeguards such as fire exits. Moreover, square meterage capacity limits of buildings in respect to covid-19 public health policy is also justified as a means for denying service. However it does just move the problem onward to the public emergency departments as their waiting rooms too are not immune to overcrowding. What is likely required of the private sector then is to respond to the increased demands for their service from the public by investing in larger departments with more beds and have a more robust number of specialist services available during peak and off peak times.

As alluded to above, private emergency departments are a business and therefore have a right to decline to enter into a relationship with a patient whereby there is an exchange of money for medical care. This is perfectly legal in the eyes of business law assuming the decline is not founded on a basis of discrimination towards a patient’s sex, ethnicity, religious beliefs, sexuality, etc. This plays into the private department’s desire to maintain their business reputation as a place where patients can access emergency medical care without the waiting times of the public system. In my opinion this reason falls short of being justified for denying service to patients. It is a dishonest practice that oftentimes goes against the morals and values by which the private hospitals are founded upon. The public should be made very aware of this practice everytime it happens so they can better judge the character and values of the businesses in which they are choosing to engage in a relationship with.

Refusing service to maintain a facade of shorter waiting times than the public system does not mean the patient does not seek emergency care. The patient is obviously not left in the community by the attending ambulance staff, rather they are conveyed to a public emergency department. This further burdens the public system not only with the physical presence of the patient, but also with the cost of administering their healthcare which is now being absorbed by the taxpayers, instead of being willingly shared by the patient and their private health insurance provider. As more and more patients are redirected to the public emergency departments this further delays care for everyone else, and has very real impacts on patient morbidity and mortality.

Some patients access all of their regular healthcare providers and medical specialists through the private healthcare system. Denying them the chance to be examined at their private emergency department of choice can cause delays in being assessed by their regular specialist. Doctors who are unfamiliar with the patient in the public system will often need to restart many aspects of history taking and examination which precipitates unnecessary laboratory/imaging investigations. This can be a frustrating and exhausting experience for the patient, distracting them from placing their own energy into returning to a state of physical wellness.

It also needs to be considered that some patients may choose the private system because they have had a previous bad experience at a public emergency department or hospital. Trauma around what is perceived as a disrespectful or hurtful interaction in a certain hospital during a time of crisis can result in ongoing trauma associated with that hospital. Further to this some patients may have emotional trauma associated with an adverse health outcome or even death of a family member or friend at a certain hospital. By denying these people the opportunity to be assessed at their private hospital of choice and forcing them into a public emergency department they may be retraumatised. This can place them in a heightened emotional state which can add to patient morbidity and mortality.

Ultimately, If patients are willing to wait for service they should be given the chance to do so regardless of how busy the private emergency departments are. It is recognised that there are some very limited conditions in which the private hospitals are justified in denying service to people wanting to come to their emergency department from the community via ambulance. However these conditions probably more accurately reflect a change in what the community wants from the private sector, which is larger departments with more specialist services available around the clock. Denying service to those traveling from the community in an ambulance to maintain the facade of prompt service to walk in patients is a dishonest practice that should be made very apparent to the public. Fortunately, the public health system will always be there to pick up the load when the private emergency departments get overwhelmed, which can cost the taxpayers money that otherwise didn’t need to be spent. Finally, denying service to patients can result in unnecessary medical workup in the public system and can potentially retraumatise patients who have existing apprehensions toward a particular public hospital.