Patients who misuse the ER should feel the financial pain
None of us wants to pay higher health insurance premiums because you went to the emergency room for a head cold.
Normal people wait to visit their doctor or an urgent care clinic in the morning. We understand the emergency room is for emergencies only. Such as life-threatening conditions where you need an ambulance.
Too many people think the ER is where they should go for a stubbed toe, but just registering at the front desk invokes a $2,000 facility charge in most cases. These are the most expensive places to receive care. Unnecessary ER visits cost Americans more than $38 billion a year, the New England Health Institute reports. That is money coming out of our pockets in higher premiums and taxes.
ERs record more than 140 million visits a year, but only 40 million are for an injury, according to the Centers for Disease Control and Prevention. Just
16.2 million visits result in hospital admission. That’s an astonishing 40 ER visits per 100 U.S. residents. Texas tops the nation with 49 per 100 people a year. The national average in 1992 was 35 visits, with serious injuries much more common.
Doctors, hospitals and insurance companies all agree that ER utilization is too high. What they cannot agree on is how to reduce it.
The Texas Department of Insurance has agreed to allow Blue Cross and Blue Shield of Texas to deny ER claims if the insurer’s doctors determine that the patient never should have gone to the ER. This is intended to deter more than 500,000 people enrolled in Blue Cross and Blue Shield health maintenance organization plans from misusing the ER, according to reporting by my colleague Jenny Deam. Cue the outrage. Insurance critics blasted the proposal as a harsh and punitive way to keep people out of ERs and forcing untrained people to diagnose whether they are having heartburn or a heart attack. The Texas Association of Freestanding Emergency Centers — which represents forprofit facilities not affiliated with hospitals — accuses Blue Cross of trying to boost profits “at the expense of everyday Texans and their medical providers.”
That’s pretty rich coming from an industry that is rarely within any insurance network and leaves patients with $8,719.10 bills for treating bronchitis or $7,000 claims for firstdegree sunburn.
If these patients had merely gone to their primary care doctors or innetwork urgent care clinics, they likely would have paid $15 for an office visit, maybe a little more if they have a high deductible.
“We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities,” Dr. Robert Morrow, president of the Houston and Southeast Texas office of Blue Cross and Blue Shield of Texas, told Deam in May.
Insurance companies are no angels. They exist to make profits and save money for employers and the government, which pay most health care bills. Insurers do this by authorizing as little health care as necessary and by paying doctors as little as possible. Patients who want more care, and providers who want more money, love to beat up on insurers.
Federal law makes emergency departments very attractive for patients seeking immediate care and doctors seeking fatter profits. ERs are open 24 hours a day, and under the prudent layperson standard, doctors must at least evaluate every person who walks in the door claiming to have a problem. Federal law also requires insurers to pay for any “emergency medical condition” regardless if the ER is in-network.
Some ERs see this as a license to print money. Hospitals put up billboards advertising ER wait times, hoping to attract walk-ins with a minor problems and good insurance. Free-standing ERs pop up in strip malls, banking on freaked-out parents refusing to let their children back in the house until their head lice are removed.
Then there are the uninsured or underinsured. These patients do not have a primary care doctor or a method of payment for an urgent care clinic. They don’t get sick leave from work, and their only opportunity to obtain care is from an ER visit late at night.
These patients usually put off going to the doctor until they or their children are seriously ill, and they often walk away with no intention to pay. We cover the cost of their inflated health care costs through higher insurance premiums and taxes.
Every effort to reduce ER overuse so far has failed under our capitalist health care system because of misplaced incentives.
By refusing to pay for misuse of an ER, Blue Cross is incentivizing patients to seek the appropriate care from the appropriate venue and, most important, at the appropriate price.
Asking people to take a little personal responsibility is not a bad thing, and it is ultimately necessary to get skyrocketing health care costs under control.