Reprinted from HEALTH PLAN WEEK, the most reliable source of
objective business, financial and regulatory news of the health insurance
industry.
By Diana
Manos, Senior Reporter
July 24, 2017 Volume 27 Issue 25
Anthem, Inc. says it is trying to save money while getting its
patients more engaged in their health care by implementing a new emergency room
policy that some critics say is too harsh. The policy, implemented in several
states, denies coverage of ER care for certain conditions that Anthem says
would be better treated at a physician’s office or urgent care center. But
physicians are up in arms about it, saying the policy is dangerous to patients’
health — and even their lives.
Anthem rolled out the policy June 1 in Missouri and July 1 in
Georgia in the individual market after a 2015 effective date in Kentucky.
“Since then, we’ve seen a reduction in Kentucky members who had repeat
avoidable ER claims,” according to Anthem spokesperson Joyzelle Davis. “And we
are seeing only a small percentage of claims in the state being denied as
unnecessary ER use cases.”
The health plan is considering expanding the policy to other
markets as well, she says.
Cathryn Donaldson, director of communications and public affairs
at America’s Health Insurance Plans (AHIP), tells AIS Health that plans work
hard to educate members on the most appropriate venues for care. This includes
providing updated provider directories, offering new technologies such
telehealth services, and promoting value-based, coordinated care.
“Going to an ED versus an outpatient center for a condition that
is not an emergency may take a patient hours longer and, typically, costs four
times more than treatment at an outpatient facility,” she says. “In fact,
visits to the ED for conditions that aren’t true emergencies waste more than
$38 billion a year, driving up health care costs and premiums.”
The Anthem policy does not apply to patients under 14 years old,
Sunday or holiday ER visits, or situations where the patient was referred to an
ER by a physician. It also doesn’t apply to members who live more than 15 miles
from an urgent care center, Davis says.
Anthem Seeing More ER Misuse
The reason for the new policy, according to Davis, is Anthem is
seeing an uptick of members going to the ER for conditions that shouldn’t be
treated there, including for itchy eyes, athlete’s foot and suture removal.
“In the end, we want our members to establish a good relationship
with their primary care physicians who can guide them on their health journey,”
she says. “That’s really at the core of it.”
Davis says Anthem’s policy is also in response to the availability
of more alternatives to ER care for Anthem members, which includes a 24/7 nurse
line that members can call and an Anthem Anywhere app that helps members find
nearby network urgent care and walk-in clinics. Anthem also offers telehealth
services for a primary care physician copay to its members, with licensed
doctors available 24/7.
In addition, via Enhanced Personal Health Care, a value-based
contracting program, Anthem encourages network primary care physicians to offer
longer office hours and to follow up with patients who went to the ER to make
sure they call their doctor first next time. More than 64,000 providers
participate in Anthem’s Enhanced Personal Health Care program, caring for 5.5
million Anthem members, Davis says.
Anthem’s ER policy is based on a list of “avoidable” or
non-emergency conditions, which it developed with four board-certified
emergency physicians, Davis says. “If a member chooses to receive care for
common ailments in the ER when a more appropriate setting is available, their
claim may be reviewed by an Anthem medical director using the prudent layperson
standard” — a standard that requires insurance coverage based on a patient’s
symptoms, not their final diagnosis, she says. “In reviewing the claim, the
medical director considers the member’s presenting symptoms that may appear to
be an emergency even if the diagnosis turned out to be a non-emergency
ailment.”
Avoidable or Emergency Symptoms?
The list is what has physicians so concerned. In May, the American
College of Emergency Physicians (ACEP) and its Missouri chapter said Anthem’s
list of medical diagnoses “is a clear violation” of the national prudent
layperson standard, which is codified in federal law including the Affordable
Care Act and is also law in more than 30 states.
ACEP is concerned that under Anthem’s new policy, a patient who
seeks emergency care suffering from symptoms that appear to be an emergency,
such as chest pain, could be denied coverage if the final diagnosis does not
turn out to be an emergency.
“Health plans have a long history of not paying for emergency
care,” says Rebecca Parker, M.D., president of ACEP. “For years, they have
denied claims based on final diagnoses, instead of symptoms. Emergency
physicians successfully fought back against these policies, which are now part
of federal law. Now, as health care reforms are being debated again, insurance
companies are trying to reintroduce this practice.”
ACEP claims that some of the diagnoses on Anthem’s list of 2,000
avoidable conditions are symptoms of medical emergencies, including chest pain
on breathing, which could be a life-threatening pulmonary embolism; acute
conjunctivitis, which if caused by gonorrhea can cause blindness; or influenza,
which kills thousands of people a year.
“If patients think they have the symptoms of a medical emergency,
they should seek emergency care immediately and have confidence that the visit
will be covered by their insurance,” Parker says. “The vast majority of
emergency patients seek care appropriately, according to the CDC, and often
times should have come to the ER sooner.”
Parker suggests Anthem may need to “manage” patients who use the
ER incorrectly, but “in an emergency situation, it’s not the time.”
ACEP is skeptical that Anthem’s policy is for the well-being of
its members. “The diagnoses they’re picking are not low-hanging fruit,” she
says. “In the last 10 years, what we’ve been seeing is every strategy is about
increasing profits. In our mind, it’s about money.”
Georgia’s ACEP chapter also came out against the policy in a June
1 statement. “We treat patients every day with identical symptoms — some get to
go home and some go to surgery,” said Matt Lyon, M.D., president of Georgia’s
ACEP Chapter. “There is no way for patients to know which symptoms are
life-threatening and which ones are not. Only a full medical work-up can
determine that.”
The American Medical Association (AMA) also got into the fray. In
a June 29 letter, AMA Executive Vice President and CEO James Madara, M.D.,
urged Anthem CEO Joseph Swedish to put an end to the policy.
“The impact of this policy is that very ill and vulnerable
patients will not seek needed emergency medical care while, bluntly, their
conditions worsen or they die.…[The policy] also reduces the value of health
insurance policies on which patients have spent thousands of dollars to have
access to care, including emergency care,” Madara wrote.
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