Crash Cart: Anthem Inc Policy Angers ACEP; Follow-Up After ED Missing; CA Nurse House Burns During Evacuation

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This week: ACEP says “Prudent Laypersons” at risk with Anthem Inc ED policy, study finds lack of follow-up after ED visits; California nurse’s house burns as she evacuates patients in Intensive Care. Join in as our editors discuss the week’s headlines.

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ACEP has stepped up its opposition to Anthem Inc’s policy of rejecting ED claims it feels may not have been necessary after a visit, which ACEP says Anthem inhibits the “prudent layperson” from seeking care for issues that may be urgent or deadly.

Nearly 70% of respondents polled by ACEP say they oppose company’s policy for emergency care when the final diagnosis turns out to be non-urgent, saying it asks patients to self-diagnose dangerously similar symptoms. The CDCP reports only 4.3% of ED visits are non-urgent. Original Article by Medscape.

William Sullivan, DO, JD: Retrospective denials of coverage. Think about this concept for a moment. If a patient comes to an emergency department with a complaint, often physicians have to do testing in order to rule in or rule out an emergency medical condition. In fact, EMTALA requires that patients presenting to the emergency department get a medical screening exam that is reasonably likely to determine whether an emergency medical condition exists. Anthem is now telling its insureds that the insureds have to be smarter than the doctors they are going to visit. Patients must now have the clinical acumen to determine whether or not their complaints represent an emergency medical condition – without the benefit of testing that emergency physicians would normally need to perform. Got that folks? Patients have to be smarter than their doctors! And if patients don’t demonstrate that level of clinical decisionmaking, they get penalized with a large medical bill for daring to seek care for what is retrospectively determined to be a “non-emergency.” What a joke. Arbitrary and capricious policies like this are probably a good indicator why Anthem is #29 on the Forbes 500, has revenues of $84 billion, and has a market cap of $43 billion.

Nicholas Genes, MD, PhD: I am glad ACEP is pushing back on this, and at the same time, we need a better strategy. Bill, in the linked Medscape report, the Anthem insurance rep specifically says – “If a patient presents with chest pain that later turns out to be gastroesophageal reflux, Anthem will pay that claim” and “I am absolutely certain we are not violating the prudent layperson standard.” Their policy may hurt their some of their customers, sometimes, but something tells me this insurance juggernaut knows what it’s doing – and their arguments are getting savvier. Our specialty is backing itself into a corner. We can’t keep pretending that nobody over-uses the ED, and no visits are avoidable. It’s a small problem – not a big number of patients, and not a big fraction of expenditures. But when we say it’s a non-issue, we’ll be seen as making the problem worse, rather than helping craft a solution. In a nation where people with really serious medical problems are struggling or going bankrupt, there will not be much sympathy for ED super-users and serial mis-users… and there will not be much tolerance for those who defend the status quo.

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A Yale University study published in the Annals of Emergency Medicine found the rate of obtaining a follow-up appointment after an ED were lower than previous studies.

It used secret shoppers to pose as patients with various types of insurance needing care after being to the ED for back pain or hypertension. Only a third could get primary care appointments within a week, and those with Medicaid faired the worst. Original Article by Fierce Healthcare.

William Sullivan, DO, JD: This isn’t a big surprise. There’s a primary care physician shortage and it is getting worse. Fewer doctors means fewer available appointments which means a longer wait for appointments. The study notes that Medicaid patients have the toughest time getting follow up appointments. Many physicians don’t take Medicaid because the insurance often pays less than the cost of providing care – in addition to all of the paperwork involved. Since Medicaid ranks are increasing with the ACA and fewer doctors accept Medicaid, the problem is compounded. Note that in the study data, 57% of the follow up physicians denied an appointment because they didn’t accept Medicaid “insurance.” Contrary to what the study authors suggest, coordinating care between emergency departments and primary care practices isn’t going to help this problem. If the appointments aren’t available or if the primary care provider doesn’t take the patient’s insurance (which is one reason why the ACA’s goal of “insuring” all patients is such a farce) then the patients aren’t going to get timely follow up care.

Nicholas Genes, MD, PhD: Bill, you just raked Anthem over the coals! And you’re right to do that – they really are a ginormous corporation, scheming to screw over patients to further enrich shareholders. But then you switch gears and ravage Medicaid as being insufficient insurance to entice physicians. It sounds like your problem with the ACA was that it didn’t go far enough – Obamacare shouldn’t have just expanded Medicaid, but offered a competitive public option for insurance, too. If that’s what you’re saying, I’m glad we finally agree! And it’s just in time, too – because this physician shortage can only end in one of two ways. Either we make it worth the doctors’ time to see patients on public insurance – or we consign these folks can be managed by PAs and NPs.

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Having moved to California from Indiana, Julayne Smith had just bought a house in California weeks prior to working an overnight shift in the ICU at Kaiser Permanente hospital in Santa Rosa during the fires

NPR tells the dramatic story of how her home burned as she helped evacuated patients. Original Article by NPR.

William Sullivan, DO, JD: What a scary story. Good wishes to all of the hospital staff going through this to help their patients. Couldn’t imagine being in that situation. I wish everyone who complained about “uncaring” hospital staff could be forced to read this article.

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