It is 5 PM on a Thursday and you have had a nagging pain in your cheek all day. You otherwise feel well, and have no obvious fever. You called your family doctor but a few minutes too late and just got the answering service. Now what? Could you have a sinus infection? What you do next has a huge bearing on the costs of the U.S. health care system and quite possibly on your budget as well.
For many of us, the next step is to hop in the car and go to the closest emergency room, where you know someone will see you. Of course, in most communities you had better bring a large book, because odds are you will be sitting in the waiting room, along with crying children and coughing adults for many hours. When you are seen, you may be prescribed an antibiotic you really do not need, because the doctor knows you have been waiting for hours and expect a prescription, and it is easier to do this than to explain why you don’t need it. Chances are that a few weeks later you are going to get a complex set of papers that seem to indicate you are on the hook for $500 of the $1250 bill from the emergency department visit.
In Massachusetts, estimates are that 39% of the annual 2.4 million ER visits were for conditions that could as easily have been cared for in a doctor’s office or urgent care setting. The costs of care in these settings differ dramatically. The average ED visit costs $1220, while the average cost of an office visit is $165, at an urgent care center $172 and in a drugstore retail clinic, $69. This huge disparity in charges has many insurers working hard to keep you out of the ED, and the bluntest tool they have to do this is to impose a huge co-pay on visits that do not result in a hospital admission or even refusing to pay at all.
This attempt to reduce inappropriate ED visits can unfortunately cut needed visits as well. If a patient is worried about the expense, they may avoid an emergency visit for a problem that clearly does need emergency care, such as chest pain or passing out. Since insurers pay based on diagnosis codes that are based on the physician’s final diagnosis after a complete evaluation and patients have symptoms, the insurer may decide your final diagnosis coded as “gastritis” did not warrant the visit when your severe chest pain and nausea clearly did suggest such an urgent visit.
Another potential problem is that even when you visit a hospital that is in your insurer’s “network,” the emergency physician group that staffs the ED may not be contracted with the insurer. A major dispute is on-going between UnitedHealthcare, America’s biggest private health insurer, and Envision Healthcare, one the country’s largest employers of doctors who cover emergency departments around the country. If they cannot find a compromise, patients visiting ED’s staffed by Envision doctors will find themselves getting enormous surprise bills come January 1.
What should you as a patient do? If you are having chest pain or trouble breathing, or if you have suffered a serious injury or have another problem that obviously needs immediate attention, call 911 and get seen. If you have a problem that can wait to be seen in your doctor’s office, it is better for your pocketbook and your health to do just that. If you do not have a family doctor, or if you feel you cannot wait until they are able to see you, try an urgent care center first. In many cases, either the on-call doctor reachable by phone or a nurse advisor paid by your health insurer can help you make this decision.
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