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Anthem asks Missourians to think twice before going to the emergency room – KCUR

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

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Anthem asks Missourians to think twice before going to the emergency room – KCUR

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Anthem asks Missourians to think twice before going to the … – St. Louis Public Radio

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

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How to Keep Emergency Rooms Focused on True Emergencies – Wall Street Journal (subscription) (blog)

Howard Forman (@thehowie) is a professor of radiology, economics, public health and management at Yale University.

Over the past few decades, hospital emergency rooms have seen a steady increase in visits. This is not surprising since the emergency department (ED) has evolved from a trauma and casualty center to a finely tuned health-care delivery system in its own right. Care that previously would take weeks to deliver can be accomplished there in mere hours. Specially trained emergency medicine physicians (a specialty that is relatively new to medicine) can provide immediate attention for a multitude of traumatic, surgical, medical and mental-health emergencies.

As the availability of ED care has exploded, primary-care and specialty physicians feel more comfortablecurtailing their after-hours clinical availability, allowingunscheduled and poorly documented patients to go to the emergency department. Not surprisingly, a significant amount of nonemergent and less-urgent care is provided in the modern emergency department. This ends up costing more money, distracting highly valued resources with less-critical needs, and disrupting the coordination of care that is better delivered by primary-care physicians.

So what do we do? There are two approaches to solving this problemand only one makes sense.

For decades, insurance companies have tried demand-side strategies to reduce emergency-department visits. ED copays are common; in many cases the copay is waived if the patient was admitted to the hospital (thus signifying, that this was, indeed, a true emergency). Most recently,Blue Cross/Blue Shield of Georgia announced that it will stop paying for ED care deemed to be nonemergent, when assessed after the fact by the insurance plan. To the casual eye, this might make sense: If the encounter is not an emergency, the patient should wait to seek outpatient care, typically at a lower cost. Aligning incentives (lower cost to the patient) with the desired behavior (avoiding the emergency room and obtaining care on a nonemergent basis from your primary-care physician or specialist) would seem logical.

The problem with this scenario is that knowing at home whether you have an emergency is more challenging than it seems. In many instances, patients evaluated in the emergency room and initially judged to have an ailment that could be treated on an outpatient basis were ultimately found to have required emergency management. All too often, for instance, physicians struggle to initially differentiate between gastrointestinal tract discomfort and more serious and even fatal conditions. Financially punishing patients after the fact for not having a heart attack or stroke or appendicitis only encourages other patients to avoid emergent care until it is too late.

In my practice as an ED radiologist, I have seen many cases where an imaging test is ordered almost as an afterthought (such as an abdominal computed tomography scan in an elderly patient), but then surprises the emergency-medicine physician with a consequential result (such as bowel obstruction) that requires surgery or other interventions. If physicians cannot presciently tell who will and who will not ultimately require lifesaving interventions just from their complaint, we should not make such a demand of our patients. A patient with chest pain may just have heartburn or they may also be experiencing a myocardial infarction (a heart attack), and they should not be discouraged by insurance companies from seeking emergency-room assistance.

Fortunately, theres an alternative approach to addressing emergency-room overuse: focusing on supply-side strategies. These include providing telephone consultation services, more accessible primary-care services (including extended and urgent care hours), and integrated delivery of health care, which certain health systems offer. These measures can reduce the demand for emergency care while meeting the immediate needs of the population. Health plans are evolving to recognize this, and integrated delivery systems are reliably lower-cost due to this attention to patient-centered care delivery. For the truly nonemergent patient, the peace of mind alone from knowing that there is an accessible voice or consultant available may be enough. Early evidence suggests that telemedicine (including telephone consultations) can decrease costs by reducing ED visits.

Public and private insurance plans are changing their models of reimbursement to physicians and hospitals to incentivize higher-value care; this, in turn, is changing practice patterns and care delivery strategies. Emergency-medicine physicians and nurses did not go into this field to take care of non-urgent patients, since it distracts from their mission to provide immediate attention to acute emergencies. They, too, would prefer that integrated care delivery models are in place to best care for every patient in a timely, high-quality and accessible way. Demand-side strategies that potentially delay life-saving care will punish patients. Instead, supply-side innovation must lead the charge for better and more responsive care delivery.

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How to Keep Emergency Rooms Focused on True Emergencies – Wall Street Journal (subscription) (blog)

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Georgia Agency To Monitor Blue Cross Emergency Room Policy – WABE 90.1 FM

The state insurance department says it will monitor the new emergency room policy of Blue Cross and Blue Shield of Georgia to make sure that it is not abused to the disadvantage of Georgia policyholders.

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Blue Cross recently told policyholders that starting in July, it will stop covering ER visits it considers to have been unnecessary. The health insurer, Georgias largest, said its pursuing the moveinvolving its coverage of individual policies due to the costs of routine primary care being administered in an ER setting. Physician groups, meanwhile, have been critical of the policy.

Jay Florence, deputy state insurance commissioner, said in a statement that the agency supports insurers attempts to reduce unnecessarily high premiums.

But Florence added, You buy health insurance to make sure you are protected when something bad happens. We are tracking our phone calls and have created a specific code for complaints related to Blue Cross Blue Shields new policy. . . . We will closely monitor this new policy to make sure that it is not abused to the disadvantage of Georgia policyholders.

Routine care is far less expensive than emergency room care, and expertsagree that unnecessary use of ERs is a financial drain on the nations health care system. But what constitutes unnecessary ER use can depend on many factors such as patients symptoms, their perception of their medical condition, their location and other issues.

Blue Cross has cited the high cost of care in formulating its policy.

Were hoping that patients go to the most appropriate setting for care, Blue Cross spokeswoman Debbie Diamond told Georgia Health News. The company has a 24/7 nurse line and online tools that are always available to help members find the right care option for their neighborhood, she added. Urgent care and retail health clinics are other alternatives for patients, Diamond told GHN.

We are not trying to keep people from the ER, she said.

“This policy threatens the safety of all Georgians. There is no way for patients to know which symptoms are life-threatening and which ones are not.” — Dr. Matt Lyon, American College of Emergency Physicians

Blue Cross said its parent company, Anthem, worked with four board-certified emergency medicine doctors to develop a list of non-emergency conditions that would be better treated by a primary care doctor than in an ER. The list includes conditions such as suture removals, athletes foot, common cold symptoms and seasonal allergies including itchy eyes, the insurer said.

The insurer said it would cover ER visits that turn out not to be emergencies if the member was directed to the emergency room by another medical provider, if the services were provided to a child under age 14, if there was no urgent care or retail clinic within 15 miles of the member, or if the visit occurred on a Sunday or a major holiday.

If a member chooses togo to an ER to receive care for the common ailments listed when a more appropriate setting is available, the claim will be reviewed by a Blue Cross medical director using the prudent layperson standard before a determination is made, Blue Cross said.

In reviewing the claim, the medical director will consider whether the member had symptoms that appeared to indicate an emergency even if the diagnosis turned out to be a non-emergency ailment, the insurer added.

Still, the American College of Emergency Physicians (ACEP) said the policy violates the prudent layperson standard, which requires that insurance coverage be based on a patients symptoms, not the final diagnosis.

Anyone who seeks emergency care suffering from apparent emergency symptoms, such as chest pain, cannot be denied coverage even if the final diagnosis does not turn out to be an emergency condition, ACEP said.

This policy threatens the safety of all Georgians, Dr. Matt Lyon, president of GeorgiasACEPchapter, said in a statement. We treat patients every day with identical symptoms some get to go home and some go to surgery. There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.

Lyon added that this action will be especially bad for Georgias rural population, who are often limited in their options for medical care.

Donald Palmisano, executive director of the Medical Association of Georgia, told WABEin May that the Blue Cross policy also might disproportionately affect the elderly, those living in rural areas and adolescents over the age of 14.

I have four children, and if theres an injury and its hard to determine the pain theyre experiencing, its hard to determine whether to go to the emergency room or not, he said.

JeffFusile, president of Blue Cross and Blue Shield of Georgia, told WABE that the cost of cares been going up so much faster than peoples earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.

He also acknowledged, There are lots of gray areas where the diagnosis wasnt so bad after all, but you have to look at the situation the person was in at the time they were in it.

Separately, Blue Cross and Anthem also have to decide whether to remain in the states health insurance exchange. (Heres a recent GHN article on that decision.)

Andy Miller is editor and CEO of Georgia Health News.

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Georgia Agency To Monitor Blue Cross Emergency Room Policy – WABE 90.1 FM

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Major Insurance Company’s Payment Decision Angers ER Doctors – NBCNews.com

It hurts when you take a deep breath. Is it a heart attack? A blood clot in the lung? An infection?

Emergency room doctors are questioning letters than have gone out to some Anthem Blue Cross/Blue Shield members in three states that threaten a crackdown on reimbursements.

“Save the ER for emergencies or cover the cost,” reads a letter sent last month to Blue Cross and Blue Shield of Georgia members.

“Going to the emergency room (ER) or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations,” it reads.

“But starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”

Similar letters have gone out to members of plans owned by Anthem, Inc. in Missouri and Kentucky.

Anthem, Inc. said it’s trying to steer patients to proper care. “What we are really trying to do is make sure that people are seeing their doctors first,” said Joyzelle Davis, communications director for Anthem, Inc.

She said patients are inappropriately showing up to emergency departments with itchy eyes and other non-emergency symptoms.

Dr. Becky Parker, president of the American College of Emergency Physicians (ACEP), said it’s about money.

“The insurance company is not on the same plane. They are not here to take care of people. They are here to make money. It’s clear that the insurance companies are looking to make money. It is about the dollar. It is not about high quality care,” Parker said.

“Our concern is that the insurance industry is trying to push this nationally.”

Related: Doctors Make Case for Obamacare or Something Like it

The 2010 Affordable Care Act lays down strict rules for covering emergency room visits. ACEP said the insurance industry is taking advantage of the Trump administration’s disregard for the ACA to push the boundaries.

“Health plans have a long history of not paying for emergency care,” Parker said.

“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. Now, as health care reforms are being debated again, insurance companies are trying to reintroduce this practice.”

Davis denies this. “It is reinforcing language that has been in the contract that has not necessarily been enforced before,” she said. She said policies still apply what is known as the “prudent layperson” standard.

Anthem defines it in the letter:

“Emergency” or “Emergency Medical Condition” means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that not getting immediate medical care could result in: (a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

But Parker said the letters and the new policies have a chilling effect on patients and could leave some with bills in the thousands of tens of thousands of dollars.

Related: You Thought it Was an Urgent Care Center Until you Got the Bill

“The ‘prudent layperson’ standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis,” ACEP said.

“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance.”

Blue Cross and Blue Shield may potentially deny a claim from someone who shows up with chest pain, ACEP said. Davis said a sharp pain with a deep breath could be a symptom of the common cold, and is not an emergency.

Parker said it’s not reasonable to expect a patient to know the difference. “I don’t know and you don’t know if that is a heart attack, a blood clot, or a collapsed lung unless I see you in the emergency room,” she said.

The last thing a doctor wants is for a potentially dying patient to hesitate, worried about a bill.

“It’s really dangerous for our patients,” Parker said.

“I had a woman the other day who was in her early 40s who came in for having a stroke,” added Parker, an emergency physician at West Suburban hospital in Oak Park, Illinois.

“She had had severe dizziness, vertigo symptoms.”

The patient had waited until office hours to come in because the co-pay on her health insurance plan to see a primary physician was $50 but it was $250 for an ER visit. The patient missed an important early window for treating her stroke, Parker said. “She told me, ‘I can’t believe I risked my life for $200.'”

Dr. Howard Forman, an expert in health policy and medical imaging at Yale, said both sides are right.

“To me, this is a problem of the system,” Forman said. “This is not about bad actors.”

Related: People Get Surprise Medical Bills in 22 Percent of ER Visits

Doctors want to work 9 to 5 and patients have few other choices outside of those hours, he said.

“There are a lot of people who go to emergency rooms for things that are not true emergencies,” Forman said.

Many may simply go because they are anxious. “That incurs a significant cost to the healthcare system,” he added.

“I don’t believe insurance companies hold down costs so they can make more profit,” Forman said. Many insurance companies simply manage programs for employers who are self-insured, meaning they pay their employee health costs themselves.

Related: ER Visits Hit Record High in 2005

That said, Forman added, ACEP has a point.

“It is really difficult to know in advance which patient is really having an emergency,” he said. “Doctors aren’t even great at predicting which patients have something terrible.”

And you cannot blame patients for using ERs. “The emergency room has become the multi-specialty clinic of the 21st century,” Forman said. “You can go to the emergency room with blood in your stool, which for most people is not an emergency, and four hours later not only be diagnosed with colon cancer but you could have already met with the oncologist,” he added.

“We provide a level of service in the ER now that is extraordinary.”

And that drives up costs. What the insurance companies say they want to do is direct people to less expensive and more appropriate options.

“If a member can’t get an appointment with their primary care doctor, most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services such as LiveHealth Online,” the Anthem letter advises.

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Major Insurance Company’s Payment Decision Angers ER Doctors – NBCNews.com

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New policy impacts emergency room visits for customers of BCBS i … – WRCB-TV

CHATTANOOGA, TN (WRCB) –

The Affordable Care Act may survive next year, but North Georgia patients who depend on it are now learning there’s a catch. Starting in July, the health insurance provider Blue Cross Blue Shield of Georgia will stop covering emergency room visits it deems unnecessary.

The insurance provider sent letters explaining the new policy to patients. It said if patients with individuals policies go to the ER and it’s not an emergency they will be stuck footing the bill.

Everyone’s definition of an emergency is totally different, said Travis Marler.

Blue Cross Blue Shield of Georgia customers have a lot to say about a new policy meant to lower the number of ER visits. They’ll try and get you. The hospitals will get you, for a tiny aspirin, they will get you for it, said Kristie Digges.

The company is steering patients who do not need emergency care to their personal physicians or urgent care clinics. They don’t want people to use the emergency room as their primary health care.

“They are supposed to accept any kind of patient. Whether it is minor, whether it is major, or a child being born, they are supposed to expect.

There are some exceptions to the new policy. It won’t apply to kids under 13 years old, members who don’t have an urgent care clinic within 15 miles of their address, or visits on Sundays and major holidays. If a baby is sick, it is an emergency to a young mother. But if my son’s hurt at his rodeo and stuff it might not be an emergency to me, said Marler.

A spokesperson with the company said patients should use their best judgment. But some people are worried patients who belong in the ER may not go. I think it is crazy. If you get a cut this big and they are saying it is not an emergency and they expect you to pay, I think it is stupid, said Digges.

The company said it was forced to take action because of the rising cost of health care. North Georgia residents said the restrictions are one more challenge in affording health care. It is not fair how insurance is today. It is hard for most people to afford it with they make.

Channel 3 checked with Blue Cross Blue Shield of Tennessee. A spokesperson here in Chattanooga said no one with Blue Cross Blue Shield of Tennessee coverage will be impacted by this change.

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Blue Cross in Georgia to limit emergency room coverage – MyAJC

The Obamacare exchangemay survive next year in rural Georgia. But patients who depend on its last remaining insurer are now learning theres a catch.

Over the past week letters have arrived at homes throughout the state giving patients a jolt. Blue Cross Blue Shield of Georgia, the only insurer on the exchange for 96 of the states 159 counties, is telling patients with individual policies that if they go to the emergency room and its not an emergency, theyll be stuck with the bill.

I am very concerned, said Dr. Matthew Keadey, who leads an organization of ER doctors. He fears patients who need the ER but arent sure they do will avoid it now. If this is fully implemented, I think were going to have deaths out there because of it.

Blue Cross move could stick Keadey and his colleagues with unpaid bills if non-emergency patients continue to come but cant pay. But patients also are concerned.

Really, like what the (heck)? said Sharon Tarver, a patient in Sumter County who has Blue Cross through the exchange, as she described her reaction when she first read the letter.

It was like, OK, well when you think about people that go when they dont have an emergency, they are taking up time for people who have an emergency, that does make sense, Tarver said. But in her area there are only two urgent care clinics, and they close at 8 p.m. and 9 p.m. She recalled two incidents in the past two years when she went to the emergency room, once with chest pain and once with a cough that reminded her of her mothers lung cancer. They both turned out to be something else.

Would she still go now, after the letter?

It depends. Its a half of one hand and half the other, she said.

Trying to change habits

A spokeswoman for Blue Cross said patients with a legitimate fear of an emergency would still be covered and that the company was forced to act by the rising cost of health care.

The policy defines an emergency as what a prudent layperson would think could pose a serious danger, and it says the insurer will decide what makes that cut. It takes effect July 1. Blue Cross says it wont apply to kids 13 and younger, members who dont have an urgent care clinic within 15 miles, or visits on Sundays and major holidays.

This is not to discourage somebody with an emergency condition who needs to go to an ER to go there, said the spokeswoman, Debbie Diamond. Health care is becoming more and more expensive. Its a way to make sure that people are getting quality and affordable care.

Many pressures may have forced the tipping point. Health care prices are always rising, and Obamacare insurance was more expensive to provide at first than companies thought. This year the Trump administration has especially rattled insurance companies by waffling on whether it would continuesubsidies key to funding Obamacare exchange plans.

Blue Cross parent company, Anthem, was reportedly leaning toward pulling out of many states exchange markets. But two weeks ago itsignaled it may stay in Georgias.

And the fact is that patients who use the emergency room like their personal clinic do waste money, a lot of it.

How much is not really known. Keadey quotes data saying a small percentage of ER patients should be getting their care somewhere else.State Rep. Terry England, a co-chairman of a committee that studied how to stabilize rural hospitals, said its much more. But neither disputes that the letter is at least partly aimed at shaking up those people who know they shouldnt be at the ER.

What Im interpreting is its because theyre trying to change habits and get people to focus on going to their physician and not to the ER, England said.

It kind of comes across as cold and callous maybe, the way that theyre doing it, he said. But at the same time, it may be one of the few ways that you actually are able to maintain hospitals andkeep the doors of hospitals openacross the state.

Keadey acknowledged the existence of problem patients. But his larger concern was patients who belong at the ER and may not go.

Patients are not trained to recognize emergencies, he said. What it really is is a barrier to emergency care. Patients will die because theyre going to think twice about going to the emergency department. One person goes and it turns out they just had reflux or a stomach problem; the next person has the symptoms and its a heart attack.

To me its one more way that were seeing the insurance company trying to take their financial responsibility and place it back on the patient.

Sore throat not enough

Diamond said Blue Cross understood patients had to use their best judgment. If you are having chest pains and it turns out to be indigestion, she said, you still thought you were having chest pains. So you could go to the emergency room.

On the other hand, she said, obvious examples where you should not go to the ER would be if you had cold symptoms; if you have a sore throat.

Blue Cross is steering those patients who dont need emergency care to their personal physicians, urgent care clinics or to Blue Cross 24-hour online medical service, LiveHealth Online. The service requires using an app on a computer or on a phone with internet service. It wont work off a rotary phone, for example.

Most people now have cellphones or computers, said Diamond, the Blue Cross spokeswoman.

Not everyone does. Middle-age policymakers might not understand that because a study by the Pew Research Center found that 95 percent to 99 percent of U.S. adults up to age 50 in 2016 used the internet one way or another. But with older people that number falls off a cliff. And with lower-income people and those in rural areas, it can be harder.

We have so many people that come to the library just to have access to a computer and the internet, said Kirk Lyman-Barner, an insurance agent in Sumter County. And thats closed in the evening of course.

Is it an emergency?

In a May 19, 2017, letter to customers, Blue Cross Blue Shield of Georgia said that starting July 1 it would no longer cover non-emergency visits to emergency rooms. This is the definition it gave for emergencies:

Emergency or Emergency Medical Condition means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:

(a) placing the patients health or the health of another person in serious danger or, for a pregnant woman, placing the womans health or the health of her unborn child in serious danger;

(b) serious impairment to bodily functions; or

(c) serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Exceptions to the rule

According to Blue Cross, the rule will not apply if:

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Blue Cross Blue Shield To Launch Emergency Room Policy – WABE 90.1 FM

Starting in July, health insurance provider Blue Cross Blue Shield will stop covering emergency room visits it deems unnecessary.

And doctors and analysts have a lot to say about it.

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Blue Cross Blue Shield is enacting this policy because it doesn’t want people to use the emergency room as their primary health care.

“The cost of care’s been going up so much faster than people’s earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system,” says JeffFusile, president of Blue Cross Blue Shield.

Fusile says BCBS wants patients to use urgent care, retail health clinics and their LiveHealth app, which are all cheaper than an ER visit.

“What this policy is directed at is regular, run-of-the mill colds, maybe even influenza. But you don’t need to go to the emergency department to get tested for whether or not you have the flu and to get a Tamiflu prescription,” says JasonHockenberry, who teaches health policy at Emory University.

Hockenberry says, in his research, he’s found many people often use the emergency room inappropriately, for urgent care rather than emergency care.

“This is a real problem. Emergency departments are expensive; they’re there for a different reason. Blue Cross is clearly staking a claim here that we’re going to try to change patient behavior,” Hockenberry says.

Donald Palmisano, president of the Medical Association of Georgia, paints a different picture when it comes to this policy: Imagine a BCBS member has chest pains in the middle of the night. He thinks it might be a heart attack, so he goes to the ER. But it turns out that it was just indigestion. Under BCBS’snew policy, he gets charged for using the emergency room inappropriately. So the next time he has chest pains, he thinks, in case it’s just indigestion, he won’t go to the ER. But this time, it’s a heart attack, and he dies.

“Blue Cross is clearly staking a claim here that we’re going to try to change patient behavior.” – Jason Hockenberry

“That’s where our physicians are concerned. Because they’re like, you know, you’re putting the patient, who doesn’t have the clinical background, to determine whether their condition is of an emergency nature,” Palmisano says.

Palmisano says this policy also might disproportionately affect the elderly, those living in rural areas and adolescents over the age of 14.

“I have four children, and if there’s an injury and it’s hard to determine the pain they’re experiencing, it’s hard to determine whether to go to the emergency room or not. It puts that added stress because you’re dealing with a loved one and you’re putting parents in a very difficult situation,” Palmisano says.

But FusileofBCBS says he knows, in medicine, it’s not always black or white.

“There are lots of gray areas where the diagnosis wasn’t so bad after all, but you have to look at the situation the person was in at the time they were in it,” Fusile says.

Remember that scenario about the man who thinks he’s having a heart attack, but it’s just indigestion? Fusile says that falls into the gray area, too. He says a panel of doctors will assess claims to make sure everyone’s getting fair coverage.

But Palmisano and Hockenberry say they’ll have to wait until the policy is implemented to see how effective it really is.

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Blue Cross Blue Shield To Launch Emergency Room Policy – WABE 90.1 FM

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