A Not Very Good Proposal to Reduce Emergency Room Visits

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 PM 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;
  • Urgi-center (co located);
  • 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.



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4 replies »

  1. This is a terrible policy and a sure way to foster a new pandemic. People who feel sick need to feel empowered to visit a professional for diagnosis, period.

    I agree with Jim that the triage system needs a complete overhaul. Speaking in legal/policy terms, re-examining liability and standards of care when it comes to triage might be a good place to start.

  2. In response to both, I’m frankly astonished. It makes no sense on virtually any level. It was very different in RI; but I’m out of that loop now. Might PCPs appeal to the CEO? Usually they have a better perspective. I’ve found that provider contracting people don’t have much perspective with regard to what to pay for and what not. I’m sorry to hear about your experience Dr. Morgan. Not sure what to say, except to keep writing about how insurers can do better.

  3. Perhaps Jim can tell us why the Blues behave this way. Do they delight in spending more money than they need to because they like to maximize revenue for hospitals? Do they think they can just blithely pass the extra costs onto employers and individuals in the form of higher premiums from which they will make more absolute profit dollars assuming they sustain their normal operating margin? Wasn’t the early history of the Blues to be a funding mechanism for hospitals and, if so, why is that attitude still apparently embedded in their culture almost 100 years after they started in business?

  4. “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.”

    And why does that happen?

    We used to open our office in the evening, on weekends, even on holidays, to see urgent cases. We’d see twenty or more patients on Thanksgiving AM, on New Years Day, on Easter afternoon. It was a win for everyone – our patients loved it, insurers saved a ton of money, we were paid fairly, and our staff got time and half and a holiday bonus.

    And then our largest payer, the local BCBS, stopped paying. No procedures with E&M codes – evaluate a patient with gastroenteritis, and we wouldn’t get a penny for the three hours of IV therapy we gave them, not even a cent for the supplies. No payment for observation when we kept a patient in the office for monitoring for eight hours. No payment for the sutures and other supplies used repairing complex lacerations. And no after hours and holiday fees, that enabled us to pay our staff appropriately.

    We sat down with the Blues. We showed them the speed sheets and the EOBs, how we could treat these patients for 5% of what the ER charged. And they didn’t give a rat f**k.

    And so we now send everyone, even a hangnail, to the ER when they call after hours or on a holiday. I’ve met with the Blues two more times since then, showing them how they’ve lost hundreds of thousands of dollars by their pig-headedness. And they DO NOT CARE.

    You write some interesting posts, but you seem to have no understanding of the absolutely disgusting contempt with which the insurers, including all the many Blues I’ve dealt with, treat physicians on a daily, on an hourly basis. And you dare to make a snide remark about how I am no longer willing to give my medical advice away for free at all hours of the day and night . . . unbelievable.

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