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Will a Payer’s New ER Policy Give Telehealth a Boost in Texas?

Blue Cross and Blue Shield of Texas is looking to screen ER visits by its members to weed out unnecessary trips to the hospital. The controversial policy may also boost direct-to-consumer teleehalth in the Lone Star State.

Source: ThinkStock

By Eric Wicklund

- A move by Texas’ largest health insurer to reduce unnecessary ER visits could provide a welcome boost to direct-to-consumer telehealth programs in the state.

Beginning in June, Blue Cross and Blue Shield of Texas will begin screening ER visits from fully insured and retail HMO members, and may decline reimbursement if the visit is out-of-network and deemed unnecessary. The insurer’s goal is to reduce hospital visits for minor ailments that are expensive and time-consuming and lead to crowded ERs.

The new policy is expected to affect about 500,000 Texans.

“Some of our members are using the emergency room (ER) for things like head lice or sprained ankles, for convenience rather than for serious or life-threatening issues,” BCBST officials said in a letter sent to affected members. “Doing so not only drives up costs for our members, but uses limited ER resources for conditions that are not serious or life threatening. We want to make health care affordable for our members, and to do so, we have to be good stewards of their money.”

While BCBST’s policy doesn’t mention telehealth, a similar strategy unveiled last year by Anthem Blue Cross Blue Shield did.

The  Indianapolis-based insurer, which administers Blue Cross Blue Shield plans in 14 states, launched its initiative last 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. The insurer has since expanded that policy to Indiana, Kentucky and Missouri.

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.

In addition, Minneapolis-based UnitedHealth has introduced a new policy to review ER claims from its most costly patients, also in an effort to steer them away from the hospital and to more appropriate care.

Prior to launching its policy, 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 was whittled down to about 300 codes – representing the most common non-emergency conditions.

In Georgia, BCBSGa officials emphasized that all ER visits are carefully screened to determine if they meet the definition of a non-emergency. They also point out the rule doesn’t apply to children under 13, Sundays or holiday visits or instances in which the member is more than 15 miles from the nearest urgent care clinic.

All of these moves have drawn strong opposition from physicians and patient advocates who worry that patients will self-diagnose and avoid an ER visit when they really do have an emergency.

“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 Indiana Business Journal last August. “If somebody has chest discomforts they’re concerned about, we think the ER is the best place for that to be evaluated.”

“They talk about being fiscally responsible. But they’re placing patients at risk,” Dr. Vidor Friedman, vice president of the American College of Emergency Physicians, told the Dallas Morning News. The national medical specialty group, based in Irving, has opposed each payer’s policy, suggesting it violates federal law.

“Health plans have a long history of not paying for emergency care,” ACEP President Rebecca Parker said in a statement issued last year. “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.” 

But BCBST officials say they’re simply trying to reduce healthcare waste by weeding out ER visits that – after later review – shouldn’t; have happened, and which could have been handled in a much less costly format.

While the emphasis is on retail clinics or the doctor’s office, it could also benefit the growing number of direct-to-consumer telehealth and telemedicine programs in Texas. Several have opened up shop in the Lone Star State since lawmakers passed sweeping new virtual care guidelines last year.


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