Not Really An Emergency by Pat Conrad MD

It still surprises me when the lay public expresses shock at how much non-emergent, piddly BS shows up to the ER.  All of us in the ER wish we could make the casual, no-pay non-emergents (usually Medicaid) pony up at least $10 or $20 before demanding to be seen for a runny nose or menstrual cramps.

Maybe Blue Cross and Blue Shield of Georgia heard us, as it sent a letter to subscribers saying, “Save the ER for emergencies — or cover the cost… 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.”  Because we know that Big Insurance is really concerned about ER overcrowding.

Of course they are not, but merely concerned with paying larger average charges for ER visits that could be more cheaply handled in private and urgent care clinics (I don’t blame them, but it’s not MY fault).  Anthem Blue Cross/Blue Shield has sent out similar letters in Missouri and Kentucky.  The president of the American College of Emergency Physicians says, “It is about the dollar. It is not about high quality care,” to which I reply, “Duh!”  Of course the ACEP prez is trying to keep her nest feathered by implying that ER care is ipso facto “high quality” (nice buzzword), and she knows very well that Big Insurance is trying to find ways to not pay for services already provided:  “For years, they have denied claims based on final diagnoses instead of symptoms,” and she counters with the “prudent layperson” standard, that would require insurance coverage be based on stated symptoms and not final diagnosis.

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A Yale health policy expert in the article says, “To me, this is a problem of the system.  This is not about bad actors.”  Well that’s obviously wrong, as it is also very much about lawyers forcing defensive medicine, sleazy Big Insurance and Medicare/’caid trying not to pay claims, and whiny patients and family members who run to the ER for the slightest discomfort and demand that everything be done.   It’s hard to blame the ER docs on this one when they are on-site, plenty busy, and not enticing patients inside.

Third-party payers trying to force patients to pay for non-emergencies will have some interesting side effects.  The biggest will be ER docs increasingly documenting such that an emergency condition appears in order to increase the likelihood of payment, sort of a fun variant of “up-coding”.  Oh, we won’t actually fake anything, but there is probably a way to justify labs and an abdominal CT for a diaper rash if we look hard enough.  While Medicare keeps trying to tie patient satisfaction scores to payment, expect those scores to drop and to be used in justifying penalties.   While new pressure will be brought against ER docs to lower the average number of emergent workups, expect the trial lawyers to exert counter-pressure to continue encouraging excessive and expensive workups; and they will be increasingly retained by patients with even minimal bad outcomes who have determined there was poor care …once they get the bill.

I’m too much of a cynic to really buy the ACEP prez worrying, “It’s really dangerous for our patients,” concerned that they will delay seeking care for fear of a bill.  That may deter a few, but the bulk of those affected will have non-emergency diagnoses after the big workup, pending reimbursement crank-downs.  No, this is all about Big Insurance trying to justify non-payment, and the targeted physicians who want to get paid trying to work up a good PR effort in defense.  This is how physicians have screwed it up for decades:  the AMA, AAFP, ACEP, et al come out wringing their hands over “our patients” when in truth they are primarily worried about getting correctly paid for good work they already did, and they ought to just say so.

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100780cookie-checkNot Really An Emergency by Pat Conrad MD