based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.