Insurers steer Ga. patients toward ER alternatives

Three years ago, an ER copay was around $100; today, it's closer to $200, and more insurers are declining claims for nonemergency uses of the ER

By Misty Williams
The Atlanta Journal-Constitution

ATLANTA — Blue Cross Blue Shield maps out less expensive way to get treatment.

Each year, hospitals provide billions of dollars in emergency room care to patients who could be treated in less costly settings such as urgent care centers — exacerbating rising health care costs for medical providers, insurers and consumers alike.

Insurers are tackling the growing problem by offering better information about ER alternatives — hopefully helping their members avoid high out-of-pocket costs in the process.

This month, Blue Cross Blue Shield of Georgia launched a program aimed at steering its 2.8 million members away from unnecessary ER visits by using technology — including a Google Maps application — to educate them on their options. With the map program, which will eventually include a mobile app, members can find a nearby clinic by typing in an address or a ZIP code.

Some people who have insurance might not have their own doctor; others feel they can't wait until they can get a doctor's appointment. Another factor is lack of awareness that there are other options.

"I was always bewildered by why people would come to the ER for things like strep throat or an earache during the middle of the day," said Dr. Manish Oza, an ER physician who helped spur the initiative for the insurer's parent company, WellPoint.

Roughly 11 percent of ER visits for Blue Cross members in Georgia could be avoided by going to alternatives such as urgent care centers or retail health clinics, Oza said. People don't need to go to the ER for upper respiratory infections, earaches, insect bites and other minor ailments, he said.

For Brookhaven resident Maggie Coleman, avoiding the ER is about convenience and saving time.

In 2009, a friend drove Coleman to the ER at Northside Hospital after she fell and banged her head. While the care was good, she was there from 8 p.m. to 2 a.m. — spending most of the time just waiting.

Today, Coleman skips the ER trip and heads to North Atlanta Urgent Care just three miles from her home for a fall or an infection.

"Even when they're really jammed, I'm usually in and out of there in under an hour," she said.

Nationwide, an estimated 17 percent of ER visits could be treated at retail health clinics or urgent care centers — saving up to $4.4 billion, according to a 2010 study by the RAND Corp., a nonprofit research group. An average ER visit for strep throat costs $600, compared with $110 to $130 in an urgent care center or less than $100 in a retail health clinic, Oza said.

For consumers, ER copays can add up, too. Three years ago, an ER copay was around $100; today, it's closer to $200, and more insurers are declining claims for nonemergency uses of the ER, said Garry Hill, manager of the group benefits practice at insurance brokerage firm Sterling Risk Advisors.

Copays for an ER alternative, meanwhile, range from $25 to $60, Oza said.

Insurance companies receive larger bills for ER visits, and those increased costs are reflected in higher premiums for consumers, said Walt Cherniak, a spokesman for insurance giant Aetna.

Efforts by insurers to address the issue include staffing 24-hour nurse triage lines, calling members who frequent the ER to find out why, and giving grants to community health clinics to expand capacity.

In addition to using Google Maps, the Blue Cross program offers an online tutorial that helps members decide whether they need to go to an ER or a clinic, and they can call a 24-hour-a-day nurse line for advice or directions to a clinic.

Blue Cross already contracts with 90 urgent care centers throughout the state and 60 retail health clinics in metro Atlanta and Gainesville, and it is recruiting more. Retail health clinics are walk-in clinics staffed by nurse practitioners and located in CVS, Walgreens, Target and other stores.

Retail clinics began popping up in 2000 and now number nearly 1,200 nationwide.

As for its new program, WellPoint plans to roll it out across all of its 14 states by the end of April.

These nonemergency visits are also a burden for ERs, which are already struggling with overcrowding. So hospitals want to address the problem, too.

Some are opening urgent care clinics and encouraging patients who show up to the ER to seek treatment there instead. Others post ER wait times on their websites.

"Nobody wants to go to the hospital emergency room on a Saturday night," said Kevin Bloye, a spokesman for the Georgia Hospital Association, "and wait six or seven hours just to be seen."

Copyright 2011 The Atlanta Journal-Constitution

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