Hospital ER marketing may undercut an Obamacare goal

It’s easier than ever to get into your neighborhood ER.

HCA’s four local hospitals — Sunrise, Sunrise Children’s, MountainView and Southern Hills — advertise ER wait times on billboards. St. Rose Dominican’s three ERs offer InQuicker, which lets people with non-emergency issues check in online and wait at home until a doctor can see them. And the Valley Health System’s online ER Reserve schedules patients with sore throats, earaches, coughs or muscle strains for its Valley, Summerlin, Centennial Hills, Spring Valley and Desert Inn emergency departments.

Of course, if you’re having a heart attack, you’ll skip to the head of the line. But industry experts disagree on whether it’s good to encourage patients with minor problems to head to the ER.

It’s an important debate as the Affordable Care Act, or Obamacare, phases in: By opening coverage to the uninsured — including more than 600,000 uncovered Nevadans — one major goal is to shift people out of ERs and into family practices for preventive care. That puts ER marketing somewhat out of sync with federal policy, said David E. Williams, president of the Health Business Group, a Boston consulting firm.

It also puts hospitals out of step with insurers, who’ve launched informational campaigns to divert non-critically ill people into quick-care centers and drugstore medical clinics. To discourage ER use, insurers set copays up to 10 times higher than copays for primary-care visits. They also run nursing hotlines members can call for advice on where to get treatment.

“It (ER marketing) certainly is an interesting approach to public health,” said Dr. Elizabeth Kraft, medical director for Anthem Blue Cross Blue Shield, Nevada’s second-largest insurer. “The emergency room is an expensive place to get non-emergency care, and we want patients to have a relationship with a primary-care provider who can help them discern whether they have a true emergency.”

Hospitals counter that simplifying ER use is about what’s best for patients.

“It’s just a good way to educate the consumer on what the wait time actually is,” said Brendan Bussmann, vice president of strategic development and marketing for Sunrise and Sunrise Children’s hospitals. “They may be closer to one ER, but it’s not necessarily the fastest. We’re able to give a good update on where they can not only get the best care, but the quickest care.”

St. Rose officials said in a statement that InQuicker lets them manage ER patient flow while caring first for the most seriously ill.

The new tools are also a blow for consumers against a sometimes-frustrating medical industry, Williams said.

“A lot of times, the time a patient has is not respected, and people are left waiting for no good reason,” he said. “So it’s good to reduce wait times, and make wait times more convenient. In this regard, hospitals are just following the path of the hospitality and gaming industry in making things convenient for customers.”

ER marketing isn’t just patient-driven, Williams said.

ERs are a revenue center for hospitals. On average, 10 percent or more of revenue comes from emergency departments, Williams said. Common emergency procedures, such as CT scans and MRIs, can be very profitable. Most importantly, the ER is “the gateway to hospital admissions,” he said. For example, about 16 percent of patients at St. Rose’s ERs end up being admitted, company officials said.

But what’s important for hospital revenue has become a high-cost center for insurers, including the big, self-insured employers that dominate Nevada. ER care is more expensive because departments have excess equipment and personnel standing idle, waiting for big emergencies such as burns, trauma or heart attacks. Hospitals have to pay for that capacity. ERs also see a lot of nonpaying patients because they’re the only providers legally required to care for the uninsured. As much as 20 percent of Sunrise’s patients get uncompensated care, Bussmann said. Paying patients help make that up.

Public health and policy experts also fret over the disjointed nature of ER care. You could go to the same ER five Wednesdays in a row and see a different doctor every time, Williams said. That means ER patients don’t have a doctor regularly working with them to treat chronic illnesses.

“The most important work that primary-care folks do is prevention and counseling,” said Emily Carrier, a senior health researcher with the Washington, D.C.-based Center for Studying Health System Change. “They’re working toward not just immediate problem-solving, but long-term health care goals. It’s very important work. It’s just not what emergency departments are set up to do.”

The lack of primary-care set-up could be a problem as more Nevadans become insured. That’s especially the case with new state Medicaid enrollees, who could number more than 100,000 between January and June 2015, state estimates say. Their care is free to them, so it’s impossible to charge them more to visit the ER. And the ER may just seem more convenient, Williams said. It’s open 24-7, and “there’s a lot of advertising that indicates this is where you go,” he said.

Kraft said ER visits could rise as more people get insured, and that could push up premiums, though St. Rose executives said expanded coverage could just as easily encourage people to get primary care instead.

Either way, it should be the consumer’s choice, Bussmann said.

“It depends on what’s happening with the individual at that time, and what they feel is best to take care of their medical needs,” he said. “Health care is a very personal decision, not only in what you do on a regular basis, but what you do in an emergent situation.”

That’s particularly true given that most patients believe they’re sick when they go to the ER, Carrier said. The classic example? Crushing chest pain that turns out to be an anxiety attack. Also, Carrier coauthored a 2012 study that found just 10 percent of Medicaid patients and 6.6 percent of the privately insured went to the ER for non-urgent reasons.

Carrier said it’s also important to remember that in markets with limited doctor-to-patient ratios — and Nevada has some of the country’s worst — patients might not be able to get into a doctor’s office quickly, and the ER may be their only lifeline.

“It’s important to make sure, while you’re being mindful of resource issues, that you’re protecting the patients who are most vulnerable,” she said.

Contact reporter Jennifer Robison at jrobison@reviewjournal.com. Follow @J_Robison1 on Twitter.