United Health Care (UHC) announced in early June that it would begin refusing to process payments for unnecessary emergency room visits.

The insurance giant argued that hospital emergency rooms are too expensive, and misuse is driving up costs

This policy change was set to go into effect on July 1. However, after receiving feedback, the nation’s largest insurance company decided to delay this policy change “until at least the end of the national public health emergency period.”

The current emergency health declaration was expected to end on July 20 but was renewed on Monday for another 90 days – and many expect it will be renewed and extended at least through the end of 2021.

UHC backs up its new policy proposal with data provided by its parent company, United Health Group, which reported in 2019 that two-thirds of the nation’s 27 million annual ER visits may have been avoidable.

As ER visits can cost 12 times that of a visit to a primary-care provider’s office, this is of concern.

Granted, UHC is not the only insurer to make such a move. In 2019, Anthem Blue Cross Blue Shield announced similar policy shifts, yet these are still tied up in litigation.

What is going on here? And is this the right time for a policy change? Are ERs really being used inappropriately for care normally received through primary-care providers?

The data is mixed. ER admissions have remained steady for 2008 through 2019. In 2020, ER visits were down 27% from 2019, but patients were significantly sicker.

While a full analysis of ER visits for 2020 has not yet been done, much of the early data can be attributed to the COVID-19 pandemic – either due to infected patients or due to patients who put off important health care visits out of fear for the pandemic.

What the post-COVID-19 era will hold remains to be seen, but it seems to be too early for a policy shift of this magnitude.

Industry data is mixed.

There is a frequently cited 2013 Truven Health Analytics study – using pre-Affordable Care Act data – finding that 29% of ER visits made by privately insured patients were avoidable, while a 2017 article in the International Journal of Quality in Health Care argued that 3.3% of ER visits were avoidable.

A central problem with these studies is differing definitions of “avoidable” or “unnecessary” ER visits, which result in wide-ranging estimates. The industry needs to create better definitions and then gather its data before acting.

It is true that appropriate, symptom-based primary-care physician visits and annual wellness exams are better for both the patient and the health care system, rather than using the ER as a primary-care provider.

Yet, the problem may not be the misuse of ERs. It may be multiple problems with our overall health care system.

As I have stated before, we have a shortage of primary-care physicians in this country. Primary-care physician clinics have long wait times, and it is estimated that only 10% of the time a patient can get an appointment the day they need it.

In addition, increases in primary-care physician copays have caused many to put off symptom-based care, like sinus infections and the flu. This ultimately lands them in the ER with more expensive care.

While insurance companies are trying to be responsible and keep costs down, which should translate into lower premiums, the approach of denying ER visits may have significant negative consequences – and it may actually be dangerous.

Knowing that one’s insurance company may refuse to pay is going to cause many to rethink visiting the ER. This policy shift may cause the public to feel like they are being asked to play doctor on themselves when deciding to visit or not visit the ER.

This could have deadly consequences if someone decides against going to the ER for chest pain or stroke symptoms due to concerns about their insurance declining payment.

Public officials, health care leaders and insurance executives need to take a step back and seriously look at what is going on in our ERs and primary-care physician clinics.

If two-thirds of ER visits are truly inappropriate, as UHC claims, then we will need to formulate a plan that does not put the most needy and most vulnerable at risk.

The problem most likely is larger than inappropriate ER usage. It is the system.

The public needs to be able to get care when needs arise, but patients currently have to wait hours, or even days, to see physicians – and if a specialist is needed, it could take months.

ERs are being forced to fill this gap, which can lead to them becoming filled with patients who could not get a primary-care physician appointment and their condition either deteriorated to the point of a true health emergency or they simply went to the place they knew more timely help would be provided.

We need to avoid an adversarial relationship between ERs, insurance providers and patients. The problem is bigger than who pays for what.

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