An­them might make pa­tients ques­tion ER visit

The Mercury News Weekend - - NEWS - By Tom Mur­phy

IN­DI­ANAPO­LIS » Ali­son Wrenne was mak­ing waf­fles for her two young chil­dren one morn­ing when ab­dom­i­nal pain forced her to the floor. A neigh­bor who is a physi­cian as­sis­tant urged her to go to the emer­gency room.

Wrong de­ci­sion, ac­cord­ing to her health in­surer. Wrenne was di­ag­nosed with a rup­tured ovar­ian cyst, but An­them said that wasn’t an emer­gency and stuck her with a $4,110 bill.

“How are you sup­posed to know that?” said the 34-year- old from Lex­ing­ton, Ken­tucky. “I’m not a doc­tor ... that’s what the emer­gency room is for.”

In an ef­fort to curb un­nec­es­sary and costly ER vis­its, the Blue Cross-Blue Shield in­surer has told cus­tomers in a few U.S. states to go to the hos­pi­tal only in a real emer­gency such as a heart at­tack, stroke and ma­jor bleed­ing — or they could wind up foot­ing the bill.

An­them, the na­tion’s sec­ond- largest in­surer, wants pa­tients to con­sider al­ter­na­tives like drug­store clin­ics, nurse ad­vice hot­lines or telemedicine. In­sur­ers for years have been rais­ing ER co­pay­ments to try to de­ter un­nec­es­sary — and ex­pen­sive — vis­its, and An­them’s pol­icy marks an­other round in this long­stand­ing fight.

Even doc­tors agree the ER — an im­por­tant rev­enue source for hos­pi­tals — isn’t the best op­tion formi- nor com­plaints like si­nus in­fec­tions, rashes or an­kle sprains. They say it’s bet­ter in those cases to see a fam­ily doc­tor­who knows a per­son’s med­i­cal his­tory.

But some also worry that An­them’s clam­p­down will scare pa­tients away from the ER in an ac­tual emer­gency, es­pe­cially in cases where ma­jor prob­lems­may not seem se­ri­ous at first.

“I think it’s com­pletely un­fair to pa­tients,” said Dr. Jesse Pines, who teaches emer­gency medicine at Ge­orge Wash­ing­ton Uni­ver­sity. “It runs the risk of re­ally hurt­ing some peo­ple.”

Cus­tomers in Mis­souri and Ge­or­gia re­ceived let­ters ear­lier this year from An­them warn­ing them that mi­nor com­plaints should be checked out at places like clin­ics or ur­gent care cen­ters, where vis­its can cost $85 and $190, re­spec­tively. By com­par­i­son, An­them says a typ­i­cal ER visit costs around $1,200.

The ER should be used “as it was de­signed — to treat life-threat­en­ing ill­ness,” said Dr. Craig Samitt, An­them’s chief clin­i­cal of­fi­cer. “This is in no way meant to com­pro­mise a mem­ber’s de­ter­mi­na­tion of whether they’ve got an emer­gency.”

There are many ex­cep­tions to the ER rule: Pa­tients won’t get dinged when there isn’t an ur­gent care cen­ter nearby, if they need help on a Sun­day or ma­jor hol­i­day, if a doc­tor rec­om­mends go­ing to the ER or if some­one is un­der age 14.

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