Second-guessing patients, emergency workers
by Jesse Pines, MD July 26, 2017
In May 2017, Blue Cross Blue Shield (BCBS) of Georgia announced it will no longer cover “unnecessary” emergency department (ED) care, starting July 1. According to BCBS Georgia President Jeff Fusile, “…we have got to find a better way to do some of this stuff, taking some unnecessary spending out of the system.” Fusile would rather patients use urgent care, retail clinics, and their online app, instead of costly EDs for conditions treatable in those settings. The BCBS policy follows similar ones enacted by Anthem in New York, Kentucky, and Missouri.
To many, these policies seem well-intentioned for a fiscally responsible insurer in a country with out-of-control healthcare costs. The simple goal: drive low-acuity illness to cheaper settings, which will control costs and in turn, allow for lower premiums.
Insurers are partly right: inefficient setting selection is a real issue. It is not uncommon for emergency physicians to face situations where a panicky ED patient realizes their perceived health emergency was a false alarm. Some well known examples: a toddler with a fever and listlessness who perks up after a weight-appropriate dose of ibuprofen; a bout of severe, unrelenting abdominal pain that resolves spontaneously right after the patient is triaged and passes gas; the allergic reaction which initially felt like “throat closing” with not even a hive after some Benadryl.
Some ED patients could potentially be served elsewhere. Some patients come to the ED when they didn’t need any medical attention at all. But the reality is there is no systematic way for patients to reliably and safely determine whether their symptoms represent an emergency. Many patients are referred to the ED by their doctors, others have no easy access to physicians, and many do not know about or think they should use telemedicine during a potential health emergency.
Bottom line, it is playing with fire for BCBS and Anthem to systematically discourage ED use. Sometimes, fever and listlessness is meningitis, unrelenting abdominal pain can be a bursting appendix, and allergic reactions occasionally result in life-threatening anaphylaxis. All are potentially lethal if untreated. Insurers’ new ED deterrent policies create a new, unfair responsibility for patients: self-diagnose accurately, or else. Patients choosing incorrectly face steep financial penalties after seeking care in settings deemed “non-ideal,” decided after the fact by their insurer using their final diagnosis.
These policies will dissuade some patients from using the ED. They will also save insurers a boatload of money, allowing them to happily keep more of their members’ hard-earned premium dollars.
Yet for many, the perception of a potential health emergency will be too great to bear. The fact is most patients do not consider costs when they think they are having an emergency. No doubt, many patients in Georgia, New York, Kentucky, and Missouri will continue to pile into EDs at all hours for conditions that end up being nothing serious. But later, they will get punched in the gut by their insurer with a “surprise coverage gap”: a large out-of-pocket bill, despite already having responsibly paid their insurance premiums. Their insurers will recast this travesty as “surprise billing” by greedy physicians and hospitals.
Given the large numbers of people these policies affect, some hapless patients will err on the side of fiscal responsibility, risking their safety and well-being. They may initially think they need care, but will think twice and make the wrong decision. Deferring life-saving care will cause them to experience a poor outcome or even die.
These insurance policies ignore the realities and uncertainties that patients face during illness and injury. Patients with minor symptoms not uncommonly have serious illness, and many patients with symptoms that first seem serious end up being nothing. A 2013 JAMA article described this phenomenon: the 6% of ED patients with “primary care treatable” conditions had the same chief complaints as 89% of overall ED visits. Even for expert emergency physicians and nurses armed with advanced equipment, the art of accurate diagnosis can be deceivingly difficult. It sometimes takes an ED visit to figure out whether a condition is “primary-care treatable.”
For the American College of Emergency Physicians (ACEP), this is not its first rodeo with insurers over fair coverage. This came to a head in the late ’90s with repeated denials for ED visit claims: for example, crushing chest pain ultimately diagnosed as gastro-esophageal reflux. In the end, ACEP’s work along with patient outcry led to the “prudent layperson standard.” This requires insurers to pay for emergency conditions that, according to a person who “possesses an average knowledge of health and medicine,” potentially places someone in serious jeopardy from impairment of bodily function or dysfunction to bodily organs. The prudent layperson standard was written into federal law in the Patient Protection and Affordable Care Act of 2010. The intention of prudent layperson was to not allow insurers to make post-hoc coverage decisions. Specifically, by reviewing limited information (i.e., the discharge diagnosis), an insurer has no way of knowing what brought the patient to the ED or whether a prudent layperson would have considered their symptoms a medical emergency.
The trouble is that now BCBS Georgia thinks that it can read their beneficiaries’ minds, apply the prudent layperson standard fairly and reliably, and not pay for “non-emergencies.” Think again.
Take a 43-year-old female who whacks her foot into the door jam at 1 a.m., which is immediately painful and she can’t bear weight. The toes turn dark purple, and appear swollen and deformed. After ibuprofen, the pain becomes unbearable. She goes to the ED (the only place open), gets an x-ray and some pain control. She goes home comfortable, reassured there’s no fracture, with a surgical shoe and a prescription for painkillers. Weeks later, insurance staff reviews her claim and sees the ICD-10: “S90.1 Contusion of toe without damage to nail.” Nowhere in her insurance records did it say she had severe pain, ibuprofen was ineffective, or that she couldn’t walk. The conclusion: another “unnecessary” ED visit for a stubbed toe. She is left paying $1200 out of pocket. One night, several months later, she is awoken by chest pain. Still stinging from her “surprise coverage gap,” she goes back to sleep, hoping it’s nothing and dies from a heart attack. The only winner is her insurer, who got out of paying for not one, but two ED visits.
Where and when people should seek care when sick and injured is thorny business. The terms “inappropriate” and “unnecessary” are commonly invoked, yet never defined reliably. A recent study found that experienced emergency physicians only agreed on “ideal” settings for about half the time, even with detailed clinical information about the ED visit. Therefore, it is impossible for insurers to know with any reasonable certainty whether any particular case was “unnecessary” with the limited data they review or whether a prudent layperson would have sought medical care.
So where do we go from here? Like the many prior attempts to implement similar policies, the BCBS and Anthem coverage shell game will ultimately fail. Patients will not stand for it. ACEP and other hospital groups will fight it. However, along the way many patients who trusted their insurance company to cover their medical bills will experience a “surprise coverage gap.” For everyone who this happens to, the bill will certainly sting. Some will go bankrupt. And a few will experience avoidable medical complications or die off in the process.
Jesse Pines, MD, is a practicing emergency physician and professor of emergency medicine and health policy at George Washington University. A version of this article originally appeared at Emergency Physicians Monthly.