Three months ago, I got out of bed, took two steps, and collapsed. I had COVID, which combined with chronic low blood pressure (hypotension) and dehydration, caused me to faint.
I woke up on the floor wondering what happened.
My wife and I immediately began weighing our options. Should I go to a hospital emergency room? An urgent care center? My primary care physician’s office?
We went to the ER. Which was a good choice because I whacked my head when I fell and needed to be checked for internal bleeding. All the tests came back negative and, after being hydrated with saline solution, my blood pressure went up and I went home.
The whole episode opened my eyes to the choices consumers must make when suddenly sick or injured, and how our choices in those stressful moments have serious financial consequences.
Here are some things to know:
Isn’t the ER always the best choice?
No, not if you don’t need it. Going to the ER is very expensive. Under my insurance plan, for example, my trip to the ER in September cost $480 out of pocket. That’s because, for ER visits, my plan requires me to pay my annual $500 deductible before my full coverage kicks in. (I’m covered through my wife’s employer by one of the biggest insurers in the state. I’m including details of my coverage to illustrate the kind of issues many of us face.)
What does the ER cost after your deductible is paid?
My ER copay is $100 — once I’ve met my deductible, which is relatively low. An increasing number of consumers are opting for so-called high-deductible health plans in exchange for lower monthly premiums. For 2023, an HDHP is any plan with a deductible of at least $1,500 for an individual or $3,000 for a family. Consider your health and age in determining what makes sense for your deductible.
Does it matter whether I go to an in-network vs. out-of-network ER?
Actually, no, there is an important exception for ERs: the in-network/out-of-network distinction doesn’t apply to them. Under a federal law called the No Surprises Act, you get whatever coverage you’re entitled to at an in-network ER even if you go out of network. The law, which went into effect in 2022, recognizes that when you’re in urgent need of medical assistance, you usually don’t have the time or presence of mind to consider the network status of the nearest ER.
Does the No Surprises Act apply to urgent care centers?
No, and therefore it’s really important to know the status of the urgent care center you intend to go to. The No Surprises Act covers hospital ERs and licensed independent emergency departments, but generally not urgent care centers.
How much cheaper is it to go to an urgent care center compared with an ER?
A lot cheaper. Under my plan, I pay only a $20 copay for a visit to an in-network urgent care center, and my deductible doesn’t apply. Compare that with my $100 copay for an ER visit (after meeting my deductible).
Why is there such a big cost difference between ERs vs. urgent care centers?
It costs a lot more to run an ER. Yet research shows a large percentage of people who go to ERs don’t need that high level of care. The proliferation of urgent care centers in recent years is motivated by cost savings. Keeping the ER for only those who need it makes good financial sense for all of us.
How do I know which urgent care centers are in-network under my plan?
I recommend logging into your account on your insurer’s website to find a list of in-network urgent care centers. It’s good information to have before an emergency arises. I live in an urban area and my insurer lists several nearby in-network urgent care centers.
How do urgent care centers compare with ERs?
ERs have more physicians and diagnostic tools than an urgent care center, plus the resources of an entire hospital, including specialists. A physician is usually on duty at an urgent care center, but most patients are seen by nurse practitioners and nurses. Urgent care centers usually have an x-ray machine.
What are the differences in hours?
The ER where I went is open 24 hours, 7 days a week. The nearby urgent care center where my wife and I once went to stitch a cut finger is open 8 a.m. to 8 p.m., 7 days a week.
One possible advantage to urgent care centers is that they usually treat patients on a first-come, first-serve basis. At an ER, long waits are common as caregivers prioritize the most urgent cases.
Are there alternatives to ERs and urgent care centers?
Yes, CVS, Walgreens, and other retailers offer care. I routinely go to a CVS MinuteClinic for COVID vaccines and flu shots. My insurer covers these visits at no charge. It also provides treatment for ear and sinus infections, colds, flu, strep throat, and other minor illnesses, plus minor wounds such as non-severe cuts, blisters, and skin abrasions. My copay is $20.
What’s the difference between an urgent care center and a retail clinic?
Both are “walk-in” clinics that don’t require an appointment. Clinics are usually staffed with a nurse practitioner and don’t have the same kinds of diagnostic tools as an urgent care center. Personnel at both can write prescriptions.
What about an office visit with my PCP?
When you are sick or injured, you may want to first call your primary care physician for advice on where to go (presuming the office is open). Your PCP should be familiar with your health history and give personalized advice. Maybe it’s appropriate to deal with your issue by coming into the office. Maybe it’s enough for your PCP to call in a prescription.
After my collapse, my wife called my PCP’s office. A nurse listened to what happened, checked my medical records, then told us to go to the ER because I needed a CT scan to check for a possible brain bleed.
Under my plan, the copay for an office visit is $20 and the deductible doesn’t apply. And there’s no charge for a telephone consultation.
What ailments are generally appropriate for an ER?
To be sure, if you think you’re having a heart attack or stroke, call 911 or get to the nearest ER as fast as possible.
Here’s one list I found online of conditions most likely appropriate for an ER: severe chest pain; severe abdominal pain; wheezing or shortness of breath; paralysis; intestinal bleeding; high fevers or rash, especially among children; vaginal bleeding with pregnancy; repeated vomiting; poisoning; severe head or eye injuries; allergic reactions; and unconsciousness. This is not meant to be a complete list. When in doubt, seek the highest level of care.
What ailments are appropriate for an urgent care center?
As a general guideline, according to a list I found online, these are appropriate: fevers; flu or cold symptoms; ear infections; animal or insect bites; seasonal allergies; bronchitis; sprains and broken bones (most urgent care centers can splint and cast broken bones); cuts and bleeding that may require stitches; vomiting or diarrhea; breathing discomfort, such as moderate asthma; urinary tract infections; x-rays and lab tests; abdominal pain; and minor back pain.
Can I get assistance by phone?
Yes, some insurers (including mine) offer a 24-hour nurse line for questions about symptoms, complications from medication, and advice on where to go for treatment. Check the back of your member ID card or online for more information.
What if I have no insurance?
Federal law requires anyone arriving at a hospital emergency room to be stabilized and treated, regardless of their insurance status or ability to pay.
Medicare pays for 80 percent of ER costs but most people have supplemental insurance to cover this gap. Medicaid covers all ER costs.
What about going to an urgent care center without insurance?
Most urgent care centers and retail clinics require some form of payment at the time of service.