I once cared for a patient in her 20s who came to the emergency room for a sore throat and a rash. While she was in no acute distress, she explained that her throat hurt and unusual bumps were erupting on her hands.
But then she mentioned starting a new antibiotic. My internal alarms sounded. Her symptoms were signs of a potentially life-threatening condition that required specialty services not available at my small hospital. I arranged for transfer to a tertiary care center. The next week I received a follow-up letter from her care team. No more than 36 hours after I saw her, she was in the intensive care unit, on a ventilator, fighting for her life.
The lesson is that even if not every rash and sore throat is a life-threatening condition, life-threatening conditions don’t always present themselves as obvious emergencies.
Anthem Inc., a for-profit managed healthcare company, appears to disagree. Beginning Jan. 1, 2018, Anthem will not cover the cost of services rendered in a New Hampshire emergency room for conditions deemed, after the fact, to be non-emergent. If Anthem determines that a medical problem could have been handled at a non-emergent clinic, the patient is on the hook for the cost. This rule is also being more diligently enforced in Kentucky, Virginia, Georgia, and Missouri.
Anthem is justifying the move by pointing to significantly higher emergency room costs compared to non-emergent clinics, citing such so called “non-emergency” services as annual sports physicals, pregnancy tests and ingrown toenails. They argue this cost is inevitably passed on to consumers.
However, the list of Anthem’s non-emergent diagnoses does not stop there. Under this enforced policy, more ambiguous complaints like chest pain with breathing and bloody urine can also be deemed unworthy of an ER visit. The American College of Emergency Physicians has uncovered almost 2,000 of these non-emergent diagnoses in Missouri alone.
Hindsight is always 20/20. But patients don’t have the benefit of a medical evaluation and test results, nor the medical training to help them decide on their on whether their condition merits emergency treatment. And for that reason, the Prudent Layperson definition was added to the federal Emergency Medical Treatment and Labor Act (EMTALA) in 1994, defining an emergency condition as one that would lead a prudent layperson, with an average knowledge of medicine, to believe that his or her health is in jeopardy. It is the patient’s presenting symptoms, not the final diagnosis, that legally determines authorization and payment for emergency claims.
But even emergency physicians are not soothsayers. EMTALA mandates that no patients are turned away from the emergency room without a medical screening exam to rule out dangerous conditions. If a patient presents with chest pain, the bucket of possible diagnoses is overflowing, from benign ailments like muscle strain or heart burn, to life-threatening conditions like heart attack, pulmonary embolism or aortic dissection. Testing is often required to tease out the difference.
Anthem’s strategy of denying payments for these evaluations when certain non-emergent diagnoses are made all but ignores emergency physicians’ legal obligations under EMTALA. Regardless of Anthem’s policies, ER patients will continue to be evaluated. However, now, physicians and hospitals abiding by the law will be risking significant losses for legitimate services wherever it turns out patients cannot pay. More importantly, patients with genuine concerns face the risk of incurring a burdensome, unplanned, out-of-pocket expense. Some patients, fearing an enormous bill, may not seek help, potentially suffering dire consequences.
And, yes, amid these casualties, there may also be some reduction in non-emergent ER visits.
Rather than penalizing patients who believe their condition warrants an emergency visit, incentivizing them when they utilize appropriate services instead will likely also reduce non-emergent ER visits, and not deter patients from seeking appropriate emergency care when they should. By denying payments for certain non-emergent diagnoses determined after the fact, Anthem is merely pushing a healthcare cost hot potato off their lap and into the arms of legally obligated emergency care providers.
How many patients will suffer preventable injury or even death because they now fear a bill for a legitimate emergency department visit? That hindsight will be 20/20.
Dr. Cerundolo is a physician practicing emergency medicine in New Hampshire.
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