| Perspectives on Texas

At least one out of every three patients who visit an emergency room does not have a true emergency. As a result, ERs become overcrowded, physicians have difficulty seeing patients with real emergencies quickly, and hospitals can become so clogged that ambulances must be diverted, potentially leading to deaths.

Moreover, unnecessary overuse of the ER is a contributor to soaring health care costs. It's part of the reason Blue Cross and Blue Shield of Texas, the state's largest health insurer, says it will stop paying for some ER visits that are not real emergencies, leaving patients to foot the bill.

These unnecessary trips should be discouraged. But BCBS’s new policy falls short because it assumes patients can tell the difference between a true emergency and just feeling sick. A recent survey by our organization, the Texas Medical Center Health Policy Institute, found about half of patients who go to the ER with a non-emergency know it’s not an emergency. But the other half think it is. Do we really want to penalize people who genuinely believe their lives are at risk?

We know BCBS's plan will likely achieve its goal of reducing unnecessary ER trips. Research shows that when insurers require patients to pick up more of the cost of an ER trip, patients use the ER less often, without increasing their risk of hospitalization of death.

But the insurer should offer something else: the option for patients to avoid a financial penalty if they call a nurse triage line before heading to the ER.

Under such a system, patients who get a nurse’s approval for an ER trip would not be charged more than their usual payment for a ER visit. But those who don't could expose themselves to a large charge if the visit was deemed a non-emergency. Surely, those with an “obvious” emergency, like extreme trauma, could avoid the call. But even in that situation, a patient and those with him could get advice on what to do on the way to the ER, such as taking aspirin in the case of an evolving heart attack or stroke.

Researchers have documented that telephone triage works. One study at a children's hospital in Denver examined how nurse phone lines can help avoid overuse of the hospital. In about two-thirds of instances where parents felt their kids should go to the ER, a nurse said a visit wasn't required — and there were no negative outcomes.

In adults, the results of telephone triage have shown mixed results. Studies are complicated by the fact that some patients simply refuse to call the triage line and go directly to the ER. Use of the triage lines would likely increase markedly if there was a potential cost for not using them.

Of course, use of telephone triage raises an important question: What happens if the patient with a true emergency is advised by the nurse to stay home? There are measures in place to minimize this. First, nurse protocols are weighted toward favoring a trip to the ER. Second, the nurse can advise the patient to call back if symptoms continue or worsen. Studies show that triage lines make the wrong call in 3 to 11 percent of patients. There is clear room for improvement, and if instituted, such a system must have frequent and detailed analysis of failures. Every patient who calls the triage line should be followed up with the next day so officials can learn of possible failures and how to improve.

Importantly, the triage line should be paid for by the entity that saves money by reducing unnecessary ER visits. For those who are insured, it would be their insurer — whether it's a commercial insurance company, Medicare or Medicaid. Hospitals, meanwhile, should fund triage lines for the uninsured, since hospitals could avoid the cost of treating patients who often are unable to pay in full.

It is not fair or safe to expect lay people to always recognize a true emergency. They need help, and the use of a nurse triage line is an important tool that can help them make that critical decision.

Disclosure: Blue Cross Blue Shield of Texas has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.