WellPoint steers patients toward ED visit alternatives

WellPoint isn't telling its members never to go to the emergency department. But it is giving them point-by-point directions to alternatives.

As part of a new campaign in all 14 states where WellPoint operates BlueCross BlueShield-affiliated plans, the company offers "education" and directions to urgent care centers and retail clinics where a patient can go instead of the ED. WellPoint shows the locations on a map, with color-coded markings for retail clinics, walk-in clinics and urgent care centers.

"For many years there's been a little bit of a disconnect," said Manish Oza, MD, an emergency department physician in Baltimore and a WellPoint medical director. "I don't think we've done a good job educating our members about their emergency options. We wanted to build a program that empowers and educates members. The decision is theirs where and when they get care."

In promoting the campaign, WellPoint cited a study released by the RAND Corp. in 2010 that estimated a $4.4 billion potential savings if nonemergency cases could be removed from emergency departments. That was based on the assumption that between 13.7% and 27.1% of emergency department cases could be handled at urgent care centers and retail clinics. (See correction)

Despite the RAND report, not all experts are convinced that people with earaches, sprained ankles or sore throats are filling emergency departments and driving up the cost of care unnecessarily.

"We need to stop paying so much attention to these 'unnecessary' visits," said Sandra Schneider, MD, an emergency physician in Rochester, N.Y., and president of the American College of Emergency Physicians.

She cited a 2008 estimate from the Agency for Healthcare Research and Quality that found that emergency care accounts for only 2% of all health care costs, and a Centers for Disease Control and Prevention survey from 2008 that found only about 8% of patients are in the emergency department for nonemergency care. (Nonemergency problems were defined as those that could wait two to 24 hours before being addressed.) Of those, according to the CDC's analysis, two-thirds are at the emergency department during evenings and weekends. That's when physicians' offices and other options usually are closed, Dr. Schneider noted.

"It's fallacy to think that overall the cost of emergency care is going to go down if you direct that small number of people away from the ED," she said.

She questioned whether even under the best scenarios, eliminating nonurgent care would save much money. Whether or not those headaches and splinter cases come in, the ED has to remain open and staffed 24 hours a day, so the fixed costs remain, she said.

There's also a disconnect between the 20/20 vision of an academic review of emergency department cases and the triage process, she said. It's very difficult to know which cases are definitely not emergencies, so estimates of potential savings can be overblown because of patients whose condition is in a gray area, Dr. Schneider said.

That means it's difficult to define an "unnecessary" case in the ED, said Derek DeLia, PhD, an associate professor at Rutgers University's Institute for Health, Health Care Policy and Aging Research in New Jersey. He co-wrote a 2009 review for the Robert Wood Johnson Foundation that found that what qualifies as truly "urgent" is hard to pin down.

The review also found that uninsured patients and patients with nonurgent problems were not responsible for overcrowding in the emergency department -- it was the inability to move patients from the ED to inpatient beds.

DeLia said he often talks to emergency department physicians and doesn't see much of an appetite for driving nonurgent cases away from EDs: They can provide a break from trauma patients, and the insured ones help pay the bills. In many cases, emergency departments actually are competing for patients, promising short wait times, he said.

"The 'easy' patients, they'll sit in the waiting room a long time, and if they're willing to do that, that's not the major stressor and really not the cost driver either," he said.

In response to those who say that nonurgent care isn't as big a problem as it's made out to be, Dr. Oza said that is no reason not to address it. "Are avoidable visits the whole problem? No. But it contributes, and I think we can all agree there are people that can go [to an alternative site] with strep throat, a urinary tract infection or a laceration. We strictly want to educate and inform the member about their options."