Treating patients in a busy, crowded emergency room (ER) for an ailment that could be handled in a less expensive and intensive venue is an all too familiar problem for ER physicians and nurses. Often those less costly options are not available to patients in an acceptable time frame. Other times, minor problems that could be addressed in an outpatient setting make their way to ground zero of our healthcare system – the emergency room.
One insurance company has decided to take action against such putative abuse of the insurance policies they sell. Anthem Blue Cross Blue Shield has devised a cost-shifting scheme to deny coverage, after the fact, for care that they deem retrospectively to have been non-emergent. This judgement is made in hindsight after review of tests and examinations done in the ER. “Save the ER for emergencies – or you’ll be responsible for the cost,” they ominously informed their patients by mail.
This policy will no doubt create numerous scenarios where a patient who reasonably sought emergency care will be left with an enormous bill if Anthem, many months after the hospital visit, decides the ER visit was not “truly emergent.” For example, if a patient presented to the ER for a cough and fever, concerned about a possible pneumonia, and was found to have only a viral cold, Anthem could refuse to pay as they deem the patient’s use of the emergency room unnecessary. “Sorry, next time have a real pneumonia,” they might say in a denial letter. Such a policy, which seems to violate state and federal laws, could be financially ruinous for many of Missouri’s families. The reason people purchase health insurance is to protect against the enormous costs associated with hospital care. As anyone who has ever looked at their hospital bill knows, those charges begin as soon as they snap on that paper bracelet.
While this cost-shifting scheme may deter some from seeking non-emergent care in the ER, it will likely have dangerous and possibly deadly unintended consequences. That is because it will increase the number of patients who choose not to seek emergency care because they are afraid of being entirely responsible for an astronomical ER bill.
Sometimes a headache is a headache. Sometimes a headache is meningitis. Anthem’s scheme unreasonably places the burden on the patient to diagnose themselves, make the right decision without the benefit of medical knowledge, labs or x-rays, or possibly face huge life-changing financial repercussions. This violates the federal Prudent Layperson standard, which aims to ensure that insurance coverage is not based on the ultimate diagnosis, but on whether a prudent person, defined as someone with average knowledge of health and medicine, might anticipate serious impairment to his or her health in an emergency situation. So far, Anthem says they have only penalized 1% of claims in this manner. However, they do not say how many people chose not to seek care for real emergencies— because that is a number they cannot know.
Insurance companies have a legitimate reason to be alarmed by the costs of insuring those who misuse the emergency room. Perhaps a more appropriate first step for Anthem would be to seek out its most frequent ER users and identify the reason they are utilizing ERs so often and address those needs and educate that sub-group. Oftentimes the reasons are quite evident. Alternative options for care will require incentivizing primary care networks to improve access. In our healthcare system, where patients are becoming sicker and technology can do more and more, the opportunities for constructive systemic change must be explored. Unfortunately, Anthem Blue Cross Blue Shield’s policy of penalizing patients after the fact is self-serving for the company and will be catastrophic financially for some of their subscribers.
All of the players in this system – patients, doctors, nurses, and insurance companies - have a responsibility to make good use of healthcare resources. However, this scheme is dangerous and could potentially lead to serious illness and even death due to patients choosing to forgo seeking care for financial reasons. Missouri’s patients – the customers paying those ever-increasing premiums – deserve better.
Biography
Jonathan Patterson, MD, MSMA member since 2011, is a private practice general surgeon in Kansas City. He is a 2018 candidate for the 30th District in the Missouri House of Representatives.
Contact: jon.patterson.md@gmail.com
