Blue Cross in Georgia to limit emergency room coverage

The Obamacare exchange may survive next year in rural Georgia. But patients who depend on its last remaining insurer are now learning there's a catch.

Over the past week letters have arrived at homes throughout the state giving patients a jolt. Blue Cross Blue Shield of Georgia, the only insurer on the exchange for 96 of the state’s 159 counties, is telling patients with individual policies that if they go to the emergency room and it’s not an emergency, they’ll be stuck with the bill.

“I am very concerned,” said Dr. Matthew Keadey, who leads an organization of ER doctors. He fears patients who need the ER but aren’t sure they do will avoid it now. “If this is fully implemented, I think we’re going to have deaths out there because of it.”

Blue Cross’ move could stick Keadey and his colleagues with unpaid bills if non-emergency patients continue to come but can’t pay. But patients also are concerned.

“Really, like what the (heck)?” said Sharon Tarver, a patient in Sumter County who has Blue Cross through the exchange, as she described her reaction when she first read the letter.

“It was like, OK, well when you think about people that go when they don’t have an emergency, they are taking up time for people who have an emergency, that does make sense,” Tarver said. But in her area there are only two urgent care clinics, and they close at 8 p.m. and 9 p.m. She recalled two incidents in the past two years when she went to the emergency room, once with chest pain and once with a cough that reminded her of her mother’s lung cancer. They both turned out to be something else.

Would she still go now, after the letter?

It depends. “It’s a half of one hand and half the other,” she said.

‘Trying to change habits’

A spokeswoman for Blue Cross said patients with a legitimate fear of an emergency would still be covered and that the company was forced to act by the rising cost of health care.

The policy defines an emergency as what a “prudent layperson” would think could pose a serious danger, and it says the insurer will decide what makes that cut. It takes effect July 1. Blue Cross says it won’t apply to kids 13 and younger, members who don’t have an urgent care clinic within 15 miles, or visits on Sundays and major holidays.

“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” said the spokeswoman, Debbie Diamond. “Health care is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”

Many pressures may have forced the tipping point. Health care prices are always rising, and Obamacare insurance was more expensive to provide at first than companies thought. This year the Trump administration has especially rattled insurance companies by waffling on whether it would continue subsidies key to funding Obamacare exchange plans.

Blue Cross' parent company, Anthem, was reportedly leaning toward pulling out of many states' exchange markets. But two weeks ago it signaled it may stay in Georgia's.

And the fact is that patients who use the emergency room like their personal clinic do waste money, a lot of it.

How much is not really known. Keadey quotes data saying a small percentage of ER patients should be getting their care somewhere else. State Rep. Terry England, a co-chairman of a committee that studied how to stabilize rural hospitals, said it's much more. But neither disputes that the letter is at least partly aimed at shaking up those people who know they shouldn't be at the ER.

“What I’m interpreting is it’s because they’re trying to change habits and get people to focus on going to their physician and not to the ER,” England said.

"It kind of comes across as cold and callous maybe, the way that they're doing it," he said. "But at the same time, it may be one of the few ways that you actually are able to maintain hospitals and keep the doors of hospitals openacross the state."

Keadey acknowledged the existence of problem patients. But his larger concern was patients who belong at the ER and may not go.

“Patients are not trained to recognize emergencies,” he said. “What it really is is a barrier to emergency care. Patients will die because they’re going to think twice about going to the emergency department. One person goes and it turns out they just had reflux or a stomach problem; the next person has the symptoms and it’s a heart attack.

“To me it’s one more way that we’re seeing the insurance company trying to take their financial responsibility and place it back on the patient.”

Sore throat not enough

Diamond said Blue Cross understood patients had to use their best judgment. “If you are having chest pains and it turns out to be indigestion,” she said, “you still thought you were having chest pains. So you could go to the emergency room.”

On the other hand, she said, obvious examples where you should not go to the ER would be “if you had cold symptoms; if you have a sore throat.”

Blue Cross is steering those patients who don’t need emergency care to their personal physicians, urgent care clinics or to Blue Cross’ 24-hour online medical service, LiveHealth Online. The service requires using an app on a computer or on a phone with internet service. It won’t work off a rotary phone, for example.

“Most people now have cellphones or computers,” said Diamond, the Blue Cross spokeswoman.

Not everyone does. Middle-age policymakers might not understand that because a study by the Pew Research Center found that 95 percent to 99 percent of U.S. adults up to age 50 in 2016 used the internet one way or another. But with older people that number falls off a cliff. And with lower-income people and those in rural areas, it can be harder.

“We have so many people that come to the library just to have access to a computer and the internet,” said Kirk Lyman-Barner, an insurance agent in Sumter County. “And that’s closed in the evening of course.”

Is it an emergency?

In a May 19, 2017, letter to customers, Blue Cross Blue Shield of Georgia said that starting July 1 it would no longer cover non-emergency visits to emergency rooms. This is the definition it gave for emergencies:

“Emergency” or “Emergency Medical Condition” means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:

(a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger;

(b) serious impairment to bodily functions; or

(c) serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Exceptions to the rule

According to Blue Cross, the rule will not apply if:

  • The covered patient is 13 or younger
  • The member doesn't have an urgent care clinic within 15 miles
  • The visit happens on a Sunday or major holiday


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