American College of Emergency Physicians questions Excellus report on ER visits

The American College of Emergency Physicians (ACEP) and its New York chapter on Monday “took issue” with a new report from Excellus BlueCross BlueShield about “potentially preventable” emergency-room (ER) visits.

Excellus issued the report on April 6. In it the health insurer said that patients seeking treatment for 10 “common” conditions represent more than 2 million annual visits to hospital emergency rooms (ERs) in New York state at an estimated cost of about $1.3 billion. Research that Excellus conducted found that nine out of 10 visits to the ER for these conditions “could have been avoided or treated elsewhere.”

ACEP calls Excellus’ statistics “seriously flawed and misleading,” saying, an insurance company is using “misleading data to draw inaccurate conclusions” about whether emergency visits are appropriate.

“Health-insurance companies, and especially this one, have historically used these types of tools as a way to justify denying legitimate medical claims and padding their profits,” Dr. Jay Kaplan, president of ACEP, contended in its release. “It is very alarming that a report like this is being issued because it undermines the language in the ACA (Affordable Care Act) and patients’ responsible use of the emergency department.”

The report assesses whether emergency visits for certain conditions could have been avoided, based on the patients’ final diagnoses, “not their presenting symptoms,” according to the ACEP news release.

The Excellus data doesn’t take into consideration the national “prudent layperson” standard, which says emergency visits must be covered by insurance companies based on the patients’ symptoms, not their final diagnoses, ACEP said. This standard was included in the ACA.

The Excellus report also “directly contradicts” data from the Centers for Disease Control and Prevention which says that the vast majority (96 percent) of emergency patients seek care “appropriately,” according to ACEP.

Dr. Kaplan added that patients should never be “forced” into the position of self-diagnosing their medical conditions out of fear of insurance not covering the visit.

For example, the Excellus report cites sprains and strains as a “potentially preventable” condition in the ER.

But “does a patient have a severe strain or a broken leg?” Kaplan asked in the ACEP release.

Excellus reaction
Elizabeth Martin, VP of communications at Excellus, issued the following statement following a BJNN request for comment on the ACEP report.

“We respectfully disagree with the opinions expressed by the organization and stand by the facts issued by the New York State Department of Health regarding ‘potentially preventable’ ER visits,” said Martin.

She also forwarded copies of two studies that the New York State Department of Health conducted on the topic of emergency-room visits.

The one study issued in October 2014 focused on “New York State All Payer Potentially Preventable Emergency Room Visits 2011-2012. The study found that about 75 percent of ER visits in 2012 were “potentially preventable.”

The other study was entitled, “New York State All Payer Emergency Room Visits, 2013.” One of its findings stated that the majority of ER visits were for clinical conditions that “could have been treated or prevented” through access to “high quality primary care settings.”

Contact Reinhardt at ereinhardt@cnybj.com