Should Someone Be Punished For Using The ER?

Georgia Blues Would Charge Patients Full Freight For Unnecessary Care
By Jim Purcell

A recent article posits that an Anthem company, Blue Cross and Blue Shield of Georgia (BCBSGA), is poised to “punish” its members for “unnecessary” emergency room (ER) visits by charging subscribers the entire bill for unnecessary ER visits.  This is a variation on a theme which has been playing out in virtually every state and every insurer:  how do we reduce the number of unnecessary emergency room visits?

            Of course, expecting a lay person to be able to parse out what is medically necessary for ER care and what is not is probably expecting too much.  Example:  I’m playing softball, slide into third base (at my advanced age), and jam my leg.  I’m not sure if it is a bruise, sprain, tear, or a break.  But it hurts like hell.  It’s 7:30 p.m. on a Tuesday.  What are my options?

            Option A:  I could limp home, medicate with ibuprofen and a few beers, and hope it gets better.  When it does not, or next morning when I awake and am unable to ambulate out of my bed, what do I do then?  But of course, the pain might subside over a few days also.  My mom’s healthcare advice of wait and see might work.

            Option B:  Call my primary care physician (PCP), who is closed for the day with a message that “if this is a medical emergency, dial 911.”  That’s helpful.

            Option C:  Seek a free standing urgi-center and go there.  They likely will order x-rays, etc.  Is BCBSGA saying you can’t go there?  Unclear.

            A spokesperson for BCBSGA stated: ”…the policy wouldn’t apply when the patient is 14 or younger, an urgent care clinic isn’t located within 15 miles, or the visit occurs on a Sunday or holiday. She said it’s aimed at manifestly minor ailments — “If you had cold symptoms; if you have a sore throat. Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion.”

            The policy uses the “prudent layperson” standard, namely, what an average person would consider an emergency, not on the ultimate diagnosis reached by doctors after examinations and tests at the ER.

            I understand what BCBSGA is trying to do.  We don’t want people using ERs as their PCP.  And it might be one thing to put a $75 or $100 copay on an “unnecessary” ER visit.  But to saddle the subscriber with the entire bill?

            Were I to think that I might be saddled with the entirety of an ER visit bill (perhaps $2,000) if my view of “emergency” were not consistent with the prudent layperson test, as interpreted by the insurer’s staff who surely are not laypersons, I’d sure shy away from an ER visit.  Is that good?  Maybe and maybe not.  It will reduce ER visits; but given the “stitch in time” adage, on cases truly needing ER care who go without, the down-the-road bill may be much higher.

 

There are two possible alternatives here:
 

  • Spell out in more detail what will and will not suffice
  • Get hospital ERs to triage care in a very different way

 

Perhaps the ERs of the future have an intake specialist that directs patients in one of three directions:

 

  • Full ER
  • Urgent care
  • Send home with note to see PCP

 

Are there liability concerns?  For sure.  But those abound in every scenario.  The best defense is to establish a community standard of ER care and use that is the guideline for triage.  That at least gives one some defense against malpractice claims, which by definition require proof of a violation of the accepted community standard of care.

 

            In summary, I think the proposed course by BCBSGA is not appropriate.  We need to have professionals deciding what is medically necessary and what is not.  To that end, ERs must engage in true triaging with appropriate levels of care at appropriate costs.

 

Jim Purcell is a healthcare mediator and public speaker. A version of this article originally appeared at The Health Care Blog.