Emergency care coverage denial policies put lives at risk

A guest column by the American College of Emergency Physicians, exclusive to KevinMD.com.

Emergency medical care in the United States is a unique success story. Born from military tactics, emergency medicine has grown exponentially in size and sophistication from its early days. What was once a patchwork of inspired professionals cobbled together at a moment’s notice is now a highly esteemed medical specialty; singularly trained and expertly equipped to handle any emergency for any patient, anytime. As emergency medicine has grown, so has the demand for our services.

With more than 136 million annual patient visits, the equivalent of one in five Americans come through our doors every year. Unfortunately, misconceptions about emergency medicine could lead to dangerous policies that compromise patient care if left unchecked.

One myth is the perceived prevalence of the “unnecessary visit.” This myth is supported predominantly by insurance companies that continue trying their best to avoid compensating patients for necessary emergency care.

Insurers such as Anthem Blue Cross Blue Shield assert that people are flooding the ER with minor ailments that could be addressed in other settings, such as urgent or primary care. The reality is that the Centers for Disease Control and Prevention (CDC) tracks this trend; just over 5 percent of emergency visits are “nonurgent,” which means that nearly all (95 percent) of patients visit the emergency room with symptoms of a medical emergency.

The insurer’s flawed policy essentially functions as a fear tactic – it will force some patients to forego the emergency room out of fear they could receive a large bill. With 90 percent of symptoms overlapping between urgent and nonurgent diagnoses, there’s no way your insurer should expect you to know if your headache is a migraine or an aneurysm, or if your chest pain is indigestion or a heart attack.

The truth is that there are countless instances where a physician would not be able to tell you that without a full medical exam. That’s precisely why patient protections such as the “Prudent Layperson Standard” exist in federal and state laws. The law states that insurers are required to reimburse emergency care based on symptoms, not final diagnoses.

Emergency care coverage denial policies from insurance companies such as Anthem Blue Cross Blue Shield are misguided, unlawful and put lives at risk. Insurance companies must be expected to follow the law and action must be taken to eliminate this dangerous policy and protect patients.

Another emergency medicine myth surrounds the issue of patient “boarding.” Boarding occurs when an emergency department holds a patient for several hours, maybe even days, until a hospital bed becomes available. Boarding leads to crowding, and crowding affects every patient, those being treated and those waiting for treatment.

Boarding is a very real challenge for many emergency departments. However, the myth persists that solutions to emergency department boarding and crowding are exclusively found within the emergency department. Some erroneously believe boarding happens because of excessive wait times. But, the CDC will tell you that the median wait time nationwide is just 18 minutes. And, the average emergency visit clocks in around a fairly expedient two hours.

Boarding does not necessarily occur because of patients waiting in the waiting room. It often occurs because inpatients, people already admitted to another department in the hospital, get sent to the emergency department as a place where they can be safely stabilized until the space opens up for them.

Too often, these patients have nowhere else to go. There are countless examples and unfortunately, there are circumstances where boarding itself can compound health issues as unwell patients are stuck waiting far too long for triage or treatment.

Boarding happens to candidates for elective surgery and others with less urgent medical conditions. It happens in scenarios where patients needing psychiatric care might have to wait in the open hallway because no bed is available, and it happens to a scared child waiting for treatment.

The American College of Emergency Physicians (ACEP) has made several straightforward and high impact recommendations to improve patient flow. Solutions start with more effective time and bed management outside of the emergency department. For example, hospitals could discharge patients earlier in the day to avoid peak hours. Or, better scheduling of elective procedures could help avoid an uneven influx of patients.

The bottom line is this: Patients should not be deterred from seeking necessary care. And, when they do arrive in the emergency room they should not face avoidable delays in treatment.

There are ways to limit the small number of unnecessary visits without risking patient’s lives. And, there are ways to avoid crowding and boarding that will improve patient care while increasing hospital efficiency. Solutions to these challenges require a systemic approach and a willingness to look at the root causes instead of continuing to spread misconceptions.

Paul Kivela is president, American College of Emergency Physicians (ACEP).

Image credit: Shutterstock.com

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