Anthem: Rash? Don’t Go To The ER
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Anthem:  Rash?  Don't Go To The ER

Anthem: Rash? Don’t Go To The ER

According to the St. Louis Post Dispatch, in a recent letter to policy holders in Missouri, Anthem advised that: “Should members choose to receive non-emergency care in the ED [emergency department], they will be responsible for the charges incurred,” and that “minor conditions include sore throat, rash, mild fever, eye or ear pain and that can be “safely treated in less acute facilities.” This non-payment policy is similar to one Anthem already implemented in Kentucky and Virginia, in an effort to ‘change members’ behavior when it comes to accessing the emergency room’ in order address increasing costs to the plan for inappropriate ER use. This policy is consistent with the overall trend of health plans shifting costs, and risks, on to their policy-holders, through increasing deductibles, co-insurance payments, narrow networks, and now restricted coverage. One wonders if eventually health insurers will be out of the business of insuring risk altogether.

The consequence of such restricted coverage payment practices go beyond just shifting more of the cost of care to the patient. They now involve strategies that discourage enrollees from using the ER lest they get stuck with the entire bill for ER services. This strategy will, inevitably, backfire, when patients who should go to the ER are deterred from seeking these services, and suffer the consequences (which, of course, also increases long-term costs for the insurance company). Pictured in this blog is what appears to be a benign rash. If your sixteen year old comes to you at 10 pm complaining about this uncomfortable rash on his arm, and has a slight temp, and you go to Anthem’s website and read that Anthem might stick you for the entire ER fee for ‘inappropriate use of the ER to seek treatment for a rash, or a mild fever’; you might be persuaded to tell your son to go to bed and if the rash is no better, you will take him to an urgent care center in the morning. If so, there is a good chance your could find your child had died in his bed during the night. This rash is caused by the meningococcus bacteria, and this highly contagious and not uncommon infection can be fatal in just a few short hours.

You have seen this issue before in common stories about how manufacturers and insurance companies play the numbers and endanger consumers and policy holders in the calculated expectation that the financial risks are mitigated by the higher profits generated. Profits-made versus lives-lost is just a numbers game to them, but with this particular issue, there must be more to it. The cost of care for patients who ‘misuse the ED (the ER)’, compared to all the other costs that health insurers cover, is budget dust. In a study I did using data provided by a major health insurer, the total cost of care for the those 20% of patient visits that represented the least costly ER visits (facility plus professional ‘allowable payments’) accounted for less than 4% of the total cost for all non-admitted ER patient visits., and patients who get admitted to the hospital from the ER generate five times the ER costs of patients who are discharged.   The actual savings that might be generated by eliminating ER visits for non-emergency care probably amount to less than 0.05% of the total cost of ALL health care services covered by a health insurance plan. That is 50 cents for every $1000 spent on premiums. Why would insurance plans put patients at so much risk to save so little? Honestly, I don’t understand it, but I suspect this not just about ER services, it is about testing ways to use financial disincentives to change patient behavior. This new policy, I suspect, is just the first of many future efforts to dissuade patients from using their health insurance coverage to obtain health care services. For example, in Indiana, Anthem is rolling out a new plan that provides no out-of-nework benefits, and higher ER and Urgent Care copayments.

You might think that non-coverage payment policies like the one in Missouri would cost the plans greatly if patients start suing the plans over the consequences of this kind of manipulation, but plans have legions of lawyers who are responsible for mitigating these risks. That is why, when you go to Anthem’s website and read their recommendations about where to get care for different types of problems, you will see this disclaimer: “Call 911 or go to the emergency room if you think you could put your health at serious risk by delaying care.” In other words, the onus is on you to ignore the threat that Anthem will stick you with the entire cost of the ER visit if you think you need to go, and Anthem decides (retroactively) that you chose wrongly.  Likewise, if you are dissuaded by this threat, and chose not to go to the ER, and that was a bad decision, that’s also on you, not Anthem. Unfortunately, ‘life threatening or disabling conditions’ like the one pictured in this blog are not always recognizable as such to the ‘prudent layperson’, so when it comes to Anthem and plans like it, you pays your premium and you takes your chances.

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