- Anthem is expanding its strategy of denying payments for unnecessary ER visits, a move that could push more consumers across the country toward telehealth or mHealth services.
The insurer, which administers Blue Cross Blue Shield plans in 14 states, launched the initiative this past July in Georgia, saying members should use the payer’s telehealth service or visit an urgent care or retail clinic rather than visiting a hospital for a non-emergency health issue. Similar strategies are in place in Kentucky and Missouri.
Now Anthem is targeting Indiana. Officials say their state plans, covering some 1.1 million residents, pay for about 200,000 ER visits a year, costing millions of dollars. And those numbers are growing almost 8 percent a year.
“What we’ve seen over the last three or four years is a gradual, increased use of the emergency room,” Dr. Joseph Fox, medical director for Anthem’s Indiana operations, told the Indianapolis Business Journal. “And some of those visits could be performed at a lower-cost site of service.”
According to Anthem, an ER visit costs about $1,200 on average, compared to $190 for a visit to an urgent care center, $125 for a trip to the doctor’s office and $85 for an appointment at a walk-in clinic at a pharmacy. Consumer-facing telehealth programs, meanwhile, generally charge between $50 and $80 for an online visit.
Blue Cross Blue Shield of Georgia officials specifically mentioned their LiveHealth Online telehealth service as an alternative when announcing the ER screening policy in June.
"The cost of care's been going up so much faster than people's earnings,” BCBSGa President Jeff Fusile told Atlanta’s WABE public radio station. “We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.”
Anthem crafted a list of some 2,000 diagnosis codes that it says cover procedures that should be handled in places other than an emergency room. That list has been whittled down to about 300 codes – representing the most common non-emergency conditions – and will be applied against claims filed by Indiana members beginning October 1.
Anthem’s efforts are guided by national surveys that estimate some 75 percent of ER visits aren’t emergencies when all is said and done – Indiana-based Truven Health Analytics put that figure at 71 percent in a 2013 study. But organizations like the Texas-based American College of Emergency Physicians say that figure is much lower.
ACEP has also argued that Anthem’s list could violate federal law, including the Affordable Care Act, by shifting the focus from a person’s symptoms to the final diagnosis.
“Health plans have a long history of not paying for emergency care,” ACEP President Rebecca Parker said in a statement. “For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law.”
In addition, opponents argue that anyone who visits an ER thinks he or she has a serious medical issue, even if it’s later determined that the issue isn’t so severe. A person with chest pains could be suffering from indigestion, for instance, or having a heart attack.
“We shouldn’t put the onus on patients to make potentially very difficult medical determinations,” Dr. Richard Fogel, chief clinical officer at Indiana’s St. Vincent Health, told the IBJ. “If somebody has chest discomforts they’re concerned about, we think the ER is the best place for that to be evaluated.”
In Georgia, BCBSGa officials emphasized that all ER visits would be carefully screened to determine if they meet the definition of a non-emergency. They also pointed out the rule doesn’t apply to children under 13, Sunday or holiday visits or instances in which the member is more than 15 miles from the nearest urgent care clinic.
The insurer also sent a letter to all members explaining how it would define an emergency.
“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” BCBSGa spokeswoman Debbie Diamond told the Atlanta Journal Constitution. “Healthcare is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”
In Indiana, where officials say they expect to review about 8 percent of ER claims and reject half of them, the emphasis was also on evaluation after the fact.
“We’re not saying, ‘Don’t go to the emergency room if you have an emergency,’” Fox said, adding that members could appeal any decision made by the insurer. “We’re saying, ‘Don’t take your non-emergencies there.’”