An Excellus Blue Cross Blue Shield (BCBS) report released last week found alarmingly high numbers of "potentially unnecessary" emergency room visits.

The New York chapter of the American College of Emergency Physicians (ACEP) is blaming Excellus BCBS for looking at data based solely on a patient's actual diagnosis, not presenting symptoms that sent a patient to the emergency room. However, Excellus BCBS used an algorithm that incorporates all of a patient's background information and to it, applied local diagnosis data, the insurance agency told DOTmed News.

While the algorithm, created by New York University Center for Health and Public Service Research has weaknesses, recognized by both Excellus BCBS and the Agency for Healthcare Research and Quality, AHRQ says that the algorithm is a useful tool in looking for overall ER use in a community and assessing the size of the over-utilization problem.
The main goal of the report, the agency said, is to create public awareness about the increased use of ERs and create discussion about how to rectify the problem of frequenting the ER in seemingly unnecessary cases. The algorithm can't look at every individual patient and determine what his or her presenting symptoms and diagnoses were.

"I think where the physicians group is confused, while their criticisms are technically accurate in regard to potential weaknesses of the NYU algorithm, their [criticisms] are not accurate as it applies to the purpose we put the data out there for," Martin Lustick, Excellus BCBS senior vice president and corporate medical officer, told DOTmed News. "It's misleading for them to say we based [the report] only on discharge diagnosis."

Excellus BCBS looked at 640,000 ER visits in 2008 and found that about two out of five visits to upstate New York hospitals, in which patients don't stay overnight, could be unnecessary.

"Unnecessary visits can strain overcrowded ERs, possibly delaying treatment for those who truly need an ER, and contribute to the rising costs of health care," Jamie Kerr vice president and chief medical officer for utilization management for Excellus BCBS said in a statement.

ACEP is concerned that if the insurance company did not consider presenting symptoms then the data is skewed.

"The algorithm used to determine the conclusion didn't reflect presenting symptoms," JoAnne Tarantelli, New York's ACEPT chapter executive director, told DOTmed News. "It's based on discharge diagnosis, which only comes out after you've run tests and evaluated patients."

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