Emergency Docs Say BlueCross BlueShield Is Wrong About Unnecessary ED Visits

Cheryl Clark, for HealthLeaders Media , May 28, 2010

Excellus recommends several initiatives that will encourage patients with non-emergency conditions to go elsewhere for care, such as creating medical homes where primary care physicians coordinate patient care and starting a telephone line staffed by nurses to direct callers to the best places for their care.

Also useful would be the creation of telemedicine programs that would enroll children and simplify health information "so patients can learn how to care for themselves and avoid the ER."

Schneider of the ACEP said in a release that the Excellus report is "ironic" since Congress enacted health reforms that call for coverage for care in the emergency room under the prudent layperson standard, or whenever a patients reasonably think they may have a medical emergency, because there is a significant chance that they might.

"Health plans historically have denied coverage for emergency care, which is why this standard is needed," Schneider said. For example, a patient who thinks he or she is having a medical emergency, such as chest pain, but after examination, it is determined they have a hiatal hernia (that is not urgent) and not a heart attack," may not be covered. She said the nation's emergency physicians "have fought hard for many years to make sure health plans do not deny coverage for emergency care."

Another problem with the report is that it used a formula derived from New York University's Center for Health and Public Service Research that defines non-urgent care as that which could wait for treatment for at least 12 hours. However, the Centers for Disease Control and Prevention defines non-urgent care as that which must be provided within 24 hours, the ACEP officials said. "Patients should not be in the position of diagnosing their own medical conditions," the ACEP and its New York chapter said in a statement.

The Excellus report breaks Upstate New York into five regions, with the Western New York area and the Finger Lakes area having the greatest number of "potentially unnecessary ER visits," 183,215 and 163,074 respectively.

Excellus' vice president Kerr said "Many of the figures in the analysis are conservative," Kerr added. "The number of potentially unnecessary ER visits in upstate New York is likely larger since the report did not include visits the NYU formula deemed 'unclassifiable,' such as injuries."

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