No one likes to go to the emergency room. The good news, in most cases, is that you don't have to.
Blue Shield of California is launching a campaign this summer aimed at reducing unnecessary emergency room visits, helping plan members choose the care they need where they need it – and lowering costs for all.
Nearly 90,000 members of Blue Shield of California headed to the emergency room last year for treatment of minor illnesses like a sore throat, pink eye, or back pain, to name a few, instead of checking in with their primary care physician or pursuing other more appropriate medical options like urgent care or a 24-hour nurse hotline.
“We are not in any way trying to diminish the value of [emergency department] care,” said Dr. Robert Plass, medical policy director for Blue Shield of California. “What we’re trying to do is help people to choose the best option for them when they need care.”
When individuals visit the emergency room for certain illnesses, they end up waiting hours for care while physicians treat patients with more serious health issues and injuries. It also costs more for most members at $4,000 out of pocket for the emergency department versus $5-40 for an urgent care center visit or a $5 physician video conference via Teladoc, for example.
Blue Shield of California does not require members to first call their primary care physician when they have a cold, although some health insurers are trying to do so in other states. But the not-for-profit insurer is seeking to shift thousands of members who opt for ER to more appropriate clinical care over the next year through an educational campaign that introduces – and reintroduces – care options.
Dr. Plass, an emergency room physician, said while physicians’ fees are comparable in an emergency room or at a primary care office, the additional fees associated with an emergency room visit add unnecessary costs for the member, Blue Shield and society. An emergency room visit to treat pink eye or other avoidable ER visits, for example, can cost more than $2,000. There, members pay up to $400 out of pocket compared to a visit to the primary care physician, which is typically a co-pay of $30 to $40.
As part of its initiative, Blue Shield is looking to better understand why certain members opt to go to the emergency room instead of their primary care physician or urgent care. Starting in September, Blue Shield will begin calling members who have sought ER treatment in 2019 in what is referred to as an “avoidable ER visit,” meaning an illness or symptom that could be treated in a different setting.
Tami Reid, a Registered Nurse and a Blue Shield clinical program manager, said, the ER Member Outreach Calls team will ask members whether they are aware of their other care options, such as the 24-hour nurse hotline or the Teladoc physician video-conference, two underused services that Blue Shield has offered for years. Members may also be introduced to the nurse hotline during the survey call as a way to show the ease of contacting a nurse for immediate inquiries regarding health issues, Reid said.
Most avoidable ER use is by women and members between the ages of 18 and 34.
Reid said these members are often new to having health insurance coverage with a primary care physician, and have previously used the emergency room as their primary medical care.
Blue Shield is also exploring new ways to make it easier to choose non-emergency department care when members sprain a muscle, have a cold or eyes itch. Henry Garlich, director of Blue Shield’s Healthcare Value Solutions & Enhanced Clinical Programs, said Blue Shield is in discussions with an orthopedic group that offers ortho on demand when a member has broken a bone or sprained their wrist, or any number of skeleton fracture issues.
Garlich said Blue Shield is also looking at how to make urgent care centers more accessible in certain regions of the state where ER use is high such as Los Angeles.
For now, however, Blue Shield’s effort is member education. “What we are not doing is what others are doing. We are not going to second guess patients who go to the ER and refuse to pay their bill,” said Dr. Plass. “It’s largely helping patients understand that their share of cost is cheaper if they use a different setting.”
He adds, “ultimately the decision is theirs.”