High out-of-pocket expenses, narrow insurance networks send more patients to ERs

Patients with health insurance are ending up in the emergency room after delaying care because of high out-of-pocket costs including deductibles and co-insurance, a survey by the American College of Emergency Physicians (ACEP) found.

Seven out of 10 emergency room doctors reported seeing patients who delayed seeking care because of those high costs. Two-thirds of those surveyed also said primary care physicians are sending patients to the ER for medical tests or procedures that insurance won't cover during office visits.

"Many patients are motivated by fear of costs and not by the seriousness of their medical conditions," ACEP President Jay Kaplan, M.D., said in an announcement, criticizing insurers for shifting more costs to patients and providers. "They call it cost-cutting when in reality it is profit-boosting."

In other findings, 60 percent said they have trouble finding specialists in their patients' health insurance network for referrals, and more than 80 percent said their patients reported having trouble finding in-network specialists on their own.

A report released earlier this year by the McKinsey Center for U.S. Health System Reform said that 45 percent of plans offered on state health insurance exchanges have narrow networks--and 17 percent are defined as "ultra-narrow networks."

About three-quarters of those surveyed by ACEP also said they're seeing more Medicaid patients because insurance networks didn't include enough primary care or specialty physicians.

Such concerns have already drawn the attention of the National Association of Insurance Commissioners, which is developing a new model network adequacy law to include measures of network adequacy including provider-covered person rations by specialty and accessibility of providers by geographic area.

As a result of the challenges, 20 percent of the ACEP emergency room physicians said either they or other ER doctors they knew were considering opting out of health insurance networks. Nearly 90 percent cited insufficient reimbursement rates from insurers.

"Balance billing would not even exist if health plans paid what is known as 'usual and customary' payment in the insurance industry--what is also known as 'fair payment,'" Kaplan said in the announcement. "Emergency patients are especially vulnerable because health plans know that emergency departments never turn anyone away."

For more information:
- read the announcement
- download the ACEP survey (pdf)
- here's the McKinsey report

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