A national group of emergency room doctors and its New York chapter yesterday blasted this week's Excellus BlueCross BlueShield report that says in Upstate New York, two out of five non-overnight visits to hospital emergency departments are unnecessary.
"There are serious and profound methodological flaws in the Excellus study," said Gerard Brogan, MD, president of the New York American College of Emergency Physicians.
"Using the final discharge diagnosis rather than the presenting symptoms, ignoring that the patient with low back pain could have just as easily had a rupturing aortic aneurysm, as well as eliminating all the patients that were admitted to the hospital from the ER due to the severity of their illness, unfortunately, significantly weakens this analysis and calls into question its validity."
Sandra Schneider, president-elect of the American College of Emergency Physicians, added that the report "does not capture all the data necessary to analyze whether an emergency visit was appropriate, and it leads to false conclusions."
The report, issued May 25, focuses on 640,000 trips to emergency rooms that Upstate New York patients made for such ailments like sore throats, ear aches, upper respiratory infections, and other minor medical problems in 2008, saying that many of these patients could just as easily have gone to a primary care doctor for treatment, at much lower cost.
"Unnecessary visits can strain overcrowded ERs, possibly delaying treatment for those who truly need an ER, and contribute to the rising costs of healthcare," said Jamie Kerr, MD, vice president and chief medical officer for Excellus BCBS' utilization management. The Excellus report estimates that for commercially insured patients, annual savings would be between $5.9 million to $8.6 million if just 5% of patients went instead to a physician's office. The saving would be $29.3 million to $43.1 million if 25% sought primary care instead.
The report said that one out of four ER visits in which the patient is treated and released in the same day turned out to be for a medical issue that didn't need care within 12 hours, such as back problems.
Another 18% of visits were for medical conditions that needed treatment soon, such as an ear infection, but could have been treated in a primary care setting.
And, the report refutes a common belief that patients need the emergency department during hours when physicians don't usually keep office hours, noting that "45% of such cases are seen between 9 a.m. and 5 p.m."
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."