In a move that could impact life-or-death deliberations of millions of Americans, Anthem Blue Cross and Blue Shield affiliates throughout the country are implementing tough new guidelines for determining whether to cover emergency room visits by their policyholders.
With the cost of hospital emergency room services ballooning and many uninsured or poor people turning to ER’s for routine medical care, Blue Cross and Blue Shield affiliates in at least four states – New York, Missouri, Kentucky, and Georgia – are adopting new policies that would cover only emergency room visits deemed absolutely necessary. Others are expected to follow.
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People using emergency rooms suffering from the common cold or flu, allergy symptoms, stomach cramps, minor sprains, athlete’s foot or other routine maladies would end up having to cover the entire cost of their visits. Other more serious problems, like severe chest pains, eye infections or cuts would be assessed by the medical director to determine whether they merit coverage.
“Anthem is committed to providing access to high-quality, affordable health care,” Anthem Blue Cross and Blue Shield said in a statement on Thursday. “As part of that mission, we are committed to promoting care delivery in the most appropriate clinical setting.”
“Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patient’s health status and should be the first medical professional patients see with any non-emergency medical concerns,” the company added.
But critics warn that Anthem’s new policies could place many people in the untenable position of having to weigh a decision to rush to an emergency room against the onerous cost to them if a medical director concludes the problem wasn’t life threatening or deserving of immediate attention.
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For example, if a 72-year-old person awakens in the middle of the night with sharp chest pains and rushes to an emergency room only to learn that he or she was suffering from indigestion, that patient might get hit with tens of thousands of dollars in hospital charges not covered by the insurance company. That person might also be reluctant to return to the ER in the future in the event of another onset of chest pains, even though he or she may be in cardiac arrest.
BCBS has listed nearly 2,000 diagnoses as “non-urgent” that would not be covered by an emergency room visit. In addition to violating federal law under the Affordable Care Act, the American College of Emergency Physicians (ACEP) believes that people’s lives would be endangered. For example:
- "Chest pain on breathing" can be a life-threatening pulmonary embolism.
- "Acute conjunctivitis," if caused by gonorrhea, can cause blindness.
- "Influenza," which has killed hundreds of thousands of people over the past century, can be an emergency. Thousands of people die from the flu each year.
The law requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis. “Anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency,” the emergency physicians’ group said. Nor should insurance companies require patients to seek prior authorization before seeking emergency care.
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Blue Cross and Blue Shield officials say that with the cost of emergency room care rising at a much faster clip than inflation or average earnings, something must be done to root out unnecessary expenditures. Anthem, the giant health insurance conglomerate, currently serves 40 million people enrolled in Blue Cross and Blue Shield plans in 14 states.
A recent Johns Hopkins school of medicine analysis of more than 12,000 emergency medicine doctors across the country found that while charges varied, adult patients on average are charged 340 percent more than what Medicare pays for services. The findings were published Tuesday in JAMA Internal Medicine.
Debbie Diamond, director of public relations for the Blue Cross and Blue Shield of Georgia, the latest affiliate to announce it would adopt the new standard this summer, said in an interview today, “We’re not trying to keep people away from the emergency room. There’s a lot of discussion in health care right now about how do we keep top quality and make health care affordable. And this is one of the steps towards that. A lot of people are using the ER as their [primary care physician] and the ER was never intended to be your PCP. So what that does is just drives up the cost -- and it’s not sustainable.”
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“People that need to go to the ER should go to the ER,” she added. “People who need to see a physician when it’s not an emergency situation, should use their physician, go to a retail health clinic, use LiveHealth online and – if it’s all closed because it’s 8 o’clock at night -- then you might want to consider going to an urgent care center.”
But what about the person with serious chest pains who is debating whether to call an ambulance or rush to an emergency room?
“There’s a lot of misinformation out there,” Diamond said. “And so if you have chest pains and you go, and you thought it was a heart attack, but it turns out to be indigestion, it’s likely that it will be covered.”
That’s because the hospital medical director, following prudent lay-person standards, might conclude that the symptom “may have appeared to be an emergency, even if the diagnosis turned out to be a non-emergency ailment,” Diamond said.
Some experts agree with Blue Cross and Blue Shield about the need to discourage people from using the emergency room instead of other urgent care facilities. Others warn that the new policy will force people to make snap clinical judgments about their conditions when they are not qualified to do so.
Donald Palmisano, president of the Medical Association of Georgia told an Atlanta radio station that the hypothetical case of a patient rushing to an emergency room with chest pains, only to learn that the problem wasn’t life-threatening, is apt.
“So the next time he has chest pains, he thinks, in case it’s just indigestion, he won’t go to the ER,” Palmisano said. “But this time, it’s a heart attack, and he dies.”