The new definition for a medical emergency

The recent budget crisis in many state Medicaid programs has led the directors of these health care programs for the poor to cast about for ways to cut their costs, and many have landed on a ‘solution’ that puts lives at risk and undermine the financial viability of an emergency care safety net that is already severely underfunded and overwhelmed.  Some 21 states use a variation of the old definition of a medical emergency to determine when their state will pay, under their fee-for-service Medicaid program, for emergency care.

Under this definition, a medical emergency is, “the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.”

Now you might think that this definition covers a lot of ground; but prior to 1997 many managed care organizations and health insurers, and in particular Medicaid Managed Care plans and State Primary Care Case Management Programs, chose to limit their risk exposure by using lists of ‘emergency diagnoses’ that were very narrowly constructed.  They also required pre-authorization calls to the plans before emergency care providers in EDs were allowed to care for their enrollees.

The Balance Budget Act of 1997 changed all that and more, providing numerous protections for patients who were being put at risk by these restrictive coverage policies, including the elimination of pre-authorization and the inclusion of the “prudent layperson standard” into the definition of a covered emergency.  This new language (” … such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in …”) acknowledged that patients often can not distinguish the symptoms of a serious illness, like a heart attack, from the symptoms of less serious problems, like esophageal reflux, or heart-burn.

It also recognized that it was in everyone’s best interest, including the insurers, not to dissuade enrollees from seeking and receiving immediate attention in the ED for such symptoms.  The cost of managing the long term consequences of delaying treatment of one severe stroke or MI far exceeds the costs of screening and evaluating dozens of patients in the ED whose symptoms do not portend disaster.  Never mind the lives otherwise lost.

Unfortunately, this law seems to have protected only enrollees in managed care programs, not in Medicaid fee-for-service programs.  Although most states have adopted the prudent layperson standard for all their Medicaid programs, some 21 states have not, and many of these have begun to apply numerous restrictions on emergency care coverage, much higher co-pays for ED visits, and other policies designed to deter use of the ED, and shift the financial burden to the enrollee or, more likely, the emergency care provider, who by law must see and treat these patients whether or not the state will pay for the service.  It is a penny wise – dollar foolish approach, as the potential savings are minimal, and the risks high.  Looking at the lists of “approved emergency diagnoses” these states now use, it would appear that if these enrollees are to be covered for their ED visit, they have to be dead or dying to qualify.

In 2010, prudent layperson was extended to commercially insured enrollees through the Affordable Care Act.  It is unfortunate that this protection was not applied to every enrollee in every health insurance program.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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  • http://www.facebook.com/rob.lindeman1 Rob Lindeman

    “It also recognized that it was in everyone’s best interest, including the insurers, not to dissuade enrollees from seeking and receiving immediate attention in the ED for such symptoms [by which I believe you were referring to phrase 'less serious symptoms' from your prior paragraph]. ”
    This is nonsense.  It is in no one’s best interest to allow all comers into the emergency department for any reason, LEAST of all the individual, followed by the insurer.  It’s very good for the hospital, though.