Don’t underestimate the power of convenience. This modern commodity has given rise to the convenience store, discount stores, fast-food meals and more. Today, even health care is getting in on the idea.
Drive through many growing suburbs and you will see plenty of “close by when you need it” care choices. There are hospitals with emergency rooms (ERs) and stand-alone ERs run by hospitals. There are urgent care centers and retail health clinics. And in recent years a new player has joined the mix — the for-profit freestanding ER.
The sheer number of choices has many confused — and both consumers and insurers coughing up a lot of money.
Infographic courtesy of the Texas Association of Health Plans
Where You Go Matters: Buyer Beware
A National Institutes of Health study from 2008 found that up to 27 percent of all visits to the ER in the U.S. in a six-month time frame could have been handled at either an urgent care center or a retail health site — at much lower costs. In fact, the NIH study estimated that Americans could have saved $4.4 billion in one year simply by knowing where to go for care.
Consumers can be surprised by ER bills because they don’t fully grasp their care choices when they need care. A heart attack, for example, can only be treated in an ER. What ERs are seeing, though, are people coming to them for problems such as a sprained ankle, a cold or the flu.
Depending on what a health plan covers, a doctor could treat the sore throat for a $25 copay. You may only have a $65 copay at an urgent care center. An ER copay could be more than $100, depending on a person’s health plan. And more and more, ERs are starting to require the copay upfront for everything but life-threatening sickness or injury.
Not only may people going to an ER be hit with a higher out-of-pocket copay, but they’ll also owe the coinsurance part of the bill.
In addition, they could end up owing a huge chunk that isn’t covered by insurance. This “balance bill” could be hundreds to thousands of dollars. Balance billing happens if people go to an ER that isn’t in their health plan’s network, or if they go to the ER for something that isn’t an emergency.
Freestanding Emergency Clinics
For consumers in Texas, the explosive growth of freestanding ERs is adding to the high costs they pay for care.
Texas, with more freestanding ERs than any other state, has become the national epicenter for the growth of freestanding ERs.
The state now has more than 200 licensed for-profit freestanding ERs, with about 36 new ones licensed in 2016 alone, according to information from the Texas Department of State Health Services.
Freestanding ERs have sprouted in prime-time spots with a “build-it-and-they-will come” strategy. In fact, a new study published in Annals of Emergency Medicine found that almost all of the 200-plus freestanding ERs in Texas are located in ZIP codes where most residents have insurance and higher household incomes.
These facilities are also opening elsewhere in the country, but at a much lower rate. The states right behind Texas are Ohio with 34 and Colorado with 24.
Consumers need to be aware when thinking of using freestanding ERs. This means asking the right questions. Is this an urgent care center or an ER? Is it in my health plan’s network? What will this cost?
National Public Radio reported that many patients who visit a freestanding ER walk away with a shocking bill that can be up to four or five times higher than the urgent care center a block away.
Crowd-sourced consumer review website Yelp has seen an uptick in complaints from consumers who have visited a freestanding ER. Many say they felt duped by the facility’s lack of transparency.
“We were charged a Facility 4 charge for walking in the door with a cut for $1,575!” one reviewer said, referring to a diagnosis at a higher level than needed, which makes services cost more.
Another reviewer said, “They would not tell us any prices before we signed the paperwork, and all they kept saying was that we would be charged in-network. My husband’s nose was bleeding because he cut it ... He ended up getting a tetanus shot and Neosporin, and our bill is $2,095. This place is highway robbery!”
One reason for the sticker shock? How freestanding ERs get paid. They don’t contract with insurers to give care at a certain rate, like most hospitals or doctors do. And by not being in network, these freestanding ERs can charge much higher rates than network ERs.
“Much higher” can mean thousands, even tens of thousands, more.
The cure to exorbitant costs is as simple as consumers researching their choices, calling the number on their member ID card to ask questions and then seeking care at the right place — even if that place isn’t right around the corner.
Sources: “How Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics?", Robin M. Weinick, Rachel M. Burns, Ateev Mehrotra, RAND Corporation. Published in U.S. National Library of Medicine, National Institutes of Health, Aug. 6, 2012; Health Facilities Licensee list, Directories of Freestanding Emergency Medical Care Facilities, Texas Department of State Health Services, Online Licensing System, Sept. 13, 2016; “Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States”, Annals of Emergency Medicine, May 2015; “Patients Can Pay A High Price For ER Convenience.” Health Inc., National Public Radio, Aug. 13, 2013