Anthem Sued by Doctors in Dispute Over Emergency-Room Coverage

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The health insurer Anthem Inc. was sued by doctors in Georgia for declining to pay for some emergency-room care, escalating a long-running battle over how far insurance plans can go to push patients to seek lower-cost treatment.

The American College of Emergency Physicians and the Medical Association of Georgia filed suit on Tuesday in U.S. District Court in Atlanta against Anthem’s Blue Cross and Blue Shield of Georgia unit over the denied payments. The doctors asked the court to require Anthem to halt its policy and cover the claims.

“Providers and patients alike are operating in fear of denial of payment by defendants when patients seek emergency department care,” the groups said in the filing.

It’s the latest legal challenge over a change in policy that Anthem says was designed to cut down on patients going to an emergency room in situations that don’t require it. Emergency-room care usually costs significantly more than treatment at a doctor’s office or an urgent-care clinic. Georgia’s Piedmont Hospital and five related facilities also have sued Anthem over the policy, the Atlanta Journal-Constitution reported in February.

Before putting the policy in place, Anthem sent letters to customers explaining the policy and urging them to use other sites for care. The insurer also held meetings with physicians, according to the suit.

Anthem didn’t immediately respond to a request for comment on the suit.

Medical Records

Anthem’s strategy went beyond what’s legally allowed, the doctors say in their lawsuit. The insurer reviewed the cases of patients who went to an emergency room, and decided whether to pay for their care based on billing information or medical records related to the incident. The suit says Anthem violated legal requirements that insurers cover care in a situation where a “prudent layperson” would believe he or she was experiencing an emergency.

According to the suit, Anthem began reviewing emergency-room visits in Georgia, Kentucky and Missouri, and has also brought the policy to Ohio, New Hampshire and Indiana. Based in Indianapolis, Anthem operates under the Blue Cross and Blue Shield brand in 14 states. The company has almost 40 million health-insurance members.

Lawmakers including U.S. Senator Claire McCaskill of Missouri have criticized Anthem’s policy. McCaskill and a fellow Democrat, Senator Ben Cardin of Maryland, sent a letter in March to the Health and Human Services Department and Labor Department, asking them to investigate the payment denials.

“By denying patient claims based on the patient’s final diagnosis and ignoring the patient’s symptoms present at the time of the emergency, we believe that Anthem likely violated federal law,” the senators wrote.




Hospitals are germy, noisy places. Some acutely ill patients are getting treated at home instead.

Phyllis Petruzzelli spent the week before Christmas struggling to breathe. When she went to the emergency department on Dec. 26, the doctor at Brigham and Women’s Faulkner Hospital near her home in Boston said she had pneumonia and needed hospitalization. Then the doctor proposed something that made Petruzzelli nervous. Instead of being admitted to the hospital, she could go back home and let the hospital come to her.

As a “hospital-at-home” patient, Petruzzelli learned, doctors and nurses would come to her home twice a day and perform any needed tests or bloodwork.

A wireless patch would be affixed to her skin to track her vital signs and send a steady stream of data to the hospital. If she had any questions, she could talk via video chat anytime with a nurse or doctor.

Hospitals are germy and noisy places, putting acutely ill, frail patients at risk for infection, sleeplessness and delirium, among other problems. “Your resistance is low,” Petruzzelli said the doctor told her. “If you come to the hospital, you don’t know what might happen. You’re a perfect candidate for this.”

So Petruzzelli, who is now 71, agreed. That afternoon, she arrived home in a hospital vehicle. A doctor and nurse were waiting at the front door. She settled on the couch in the living room, with her husband, Augie, and dog, Max, nearby. The doctor and nurse checked her IV, attached the monitoring patch to her chest, and left.

When David Levine, the doctor, arrived the next morning, he asked Petruzzelli why she had been walking around during the night. Far from feeling uncomfortable that her nocturnal trips to the bathroom were being monitored, “I felt very safe and secure,” Petruzzelli said. “What if I fell while my husband was out getting me food? They’d know.”

After three uneventful days, she was “discharged” from her hospital-at-home stay. “I’d do it again in a heartbeat,” Petruzzelli said.

Brigham Health is one of a slowly growing number of health systems that encourage selected acutely ill emergency department patients to opt for hospital-level care at home.

In the couple of years since Brigham Health started testing this type of care, hospital staff who were initially skeptical have generally embraced it, Levine said. “They very quickly realize that this is really what patients want, and it’s really good care.”

This approach is quite common in Australia, Britain and Canada, but it has faced an uphill battle in the United States.

A key obstacle, clinicians and policy analysts agree, is getting health insurers to pay for it. At Brigham Health, the hospital can charge an insurer for a physician house call, but the remainder of the hospital-at-home services are covered by grants and other funding, Levine said.

Insurers don’t have a position on hospital-at-home programs, said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry trade group.

“Overall, health insurance providers are committed to ensuring patients have access to care they need, and there are Medicare Advantage plans that do cover this type of at-home care,” Donaldson said in a statement.

Levine, a clinician-investigator at Brigham and Women’s Hospital and an instructor at Harvard Medical School, was the lead author of a recently published study comparing patients who received either hospital-level care at home or in the hospital in 2016.

The 20 patients analyzed in the trial had one of several conditions, including infection, heart failure, chronic obstructive pulmonary disease and asthma. The trial found that while there were no adverse events in the home-care patients, their treatment costs were significantly lower — about half that of patients treated in the hospital.

Why? For starters, labor costs for at-home patients are lower than for patients in a hospital, where staff must be on hand around the clock. Home-care patients also had fewer lab tests and visits from specialists.

The study found that both groups of patients were about equally satisfied with their care, but the home-care group was more physically active.

Brigham Health is conducting further randomized controlled trials to test the at-home model for a broader range of diagnoses.

Bruce Leff began exploring the hospital-at-home concept more than 20 years ago, conducting studies that found fewer complications, better outcomes and lower costs in home-care patients.

Hospitals, accustomed to the traditional business model that emphasizes filling hospital beds in a bricks-and-mortar facility, have been slow to embrace the idea, however.

There are practical hurdles, too.

“It’s still easier to get Chinese food delivered in New York City than to get oxygen delivered at home,” said Leff, a professor of medicine and director of Johns Hopkins Medical School’s Center for Transformative Geriatric Research.

Since the seven-hospital Mount Sinai system in New York launched its hospital-at-home program, more than 700 patients have chosen it. And they have fared well on a number of measures.

The average length of stay for acute care was 5.3 days in the hospital vs. 3.1 days for home-care patients, while 30-day readmission rates for home-based patients were about half of those who had been hospitalized: 7.8 percent vs. 16.3 percent.

Begun with a $9.6 million federal grant in 2014, Mount Sinai’s program initially focused on Medicare patients with six conditions, including congestive heart failure, pneumonia and diabetes. Since then, the program has expanded to include dozens of conditions, including asthma, high blood pressure and serious infections such as cellulitis, and is now available to some privately insured and Medicaid patients.

Mount Sinai has also partnered with Contessa Health, a company with expertise in home care, to negotiate contracts with insurers to pay for hospital-at-home services.

Among other things, insurers are worried about the slippery slope of what it means to be hospitalized, said Linda DeCherrie, clinical director of the mobile acute care team at Mount Sinai.

Insurers “don’t want to be paying for an admission if this patient really wouldn’t have been hospitalized in the first place,” DeCherrie said.


Americans’ Views on Health Insurance at the End of a Turbulent Year

The Affordable Care Act’s 2018 open enrollment period came at the end of a turbulent year in health care. The Trump administration took several steps to weaken the ACA’s insurance marketplaces. Meanwhile, congressional Republicans engaged in a nine-month effort to repeal and replace the law’s coverage expansions and roll back Medicaid.

Nevertheless, 11.8 million people had selected plans through the marketplaces by the end of January, about 3.7 percent fewer than the prior year.1 There was an overall increase in enrollment this year in states that run their own marketplaces and a decrease in those states that rely on the federal marketplace.

To gauge the perspectives of Americans on the marketplaces, Medicaid, and other health insurance issues, the Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017, including 541 people who have marketplace or Medicaid coverage. The findings are compared to prior ACA tracking surveys, the most recent of which was fielded between March and June 2017. The survey research firm SSRS conducted the survey, which has an overall margin of error is +/– 2.7 percentage points at the 95 percent confidence level. See How We Conducted This Study to learn more about the survey methods.


Adults were asked about:

  • INSURANCE COVERAGE 14 percent of working age adults were uninsured at the end of 2017, unchanged from March–June 2017.
  • AWARENESS OF THE MARKETPLACES 35 percent of uninsured adults were not aware of the marketplaces.
  • REASONS FOR NOT GETTING COVERED Among uninsured adults who were aware of the marketplaces but did not plan to visit them, 71 percent said they didn’t think they could afford health insurance, while 23 percent thought the ACA was going to be repealed.
  • CONFIDENCE ABOUT STAYING COVERED About three in 10 people with marketplace coverage or Medicaid said they were not confident they would be able to keep their coverage in the future. Of those, 47 percent said they felt this way because either the Trump administration would not carry out the law (32%) or Congress would repeal it (15%).
  • SHOULD AFFORDABLE HEALTH CARE BE A RIGHT? 92 percent of working-age adults think that all Americans should have the right to affordable health care, including 99 percent of Democrats, 82 percent of Republicans, and 92 percent of independents.


The problem with American health care is the care

A bipartisan health care deal recently brokered by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would give states greater power over health policy. But even if this nascent legislation falters, states will likely see their influence grow through actions of the Trump administration.

If state governors are going to be in the driver’s seat, they should understand something that Congress, with its narrow focus on insurance coverage, seems to have missed: the main problem with American health care is the care. Although it is important to have stable insurance markets, changes to coverage or benefit design will ultimately do little to reduce costs or make Americans healthier.

Our health care system is stuck in the 1950s, when the prevailing epidemics were polio and influenza. Today’s public health challenges are chronic diseases like diabetes, obesity, and opioid addictionHalf of all adults — 117 million Americans — have a chronic condition; the projected cost is $794 billion in lost productivity alone between 2016 and 2030.

For the most part, chronic diseases aren’t caused by microbes but by problems for which there are no pills or vaccines: deeply rooted personal, social, financial, and behavioral issues, messy, real-life problems like job layoffs, eviction notices, or loneliness. These issues have a profound effect on health, particularly in working-class communities where health care costs are high.

Our health care system hasn’t caught up with the evolving face of disease in America. It is still mostly a workforce of doctors and nurses who dutifully treat patients in hospitals with expensive drugs and high-tech medical devices. If we could reconfigure health care to detect and address the root causes of costly illness, health reform would be a true success.

Several initiatives have laid a path forward. This year, the Center for Medicare and Medicaid Innovation will begin Accountable Health Communities, a five-year grant that enables hospitals and doctor’s offices to check their patients for real-life issues that affect health. Once these have been identified, community health workers — trained laypeople from local communities — would help support patients and connect them to resources like housing or child care. This type of support can have a profound effect on health and lower costs.

In a recent study, my colleagues and I found that a community health worker program called IMPaCT lowered hospitalizations by 30 percent and reduced cigarette smoking, obesity, the severity of diabetes, and mental illness. This model yields a 2-to-1 return on investment, which has prompted large health systems and payers to invest millions in scaling it up.

The current debate around state waivers is focused on limiting health insurance coverage or scaling back essential benefits. Maine has joined Wisconsin, Kentucky, Arkansas, and Utah in submitting waiver applications that impose premiums for Medicaid beneficiaries and coverage lockouts that bar them from re-enrolling in health insurance coverage if they lose it because of unpaid premiums. Maine anticipates that its proposed waiver would lose its members a collective 55,000 months of coverage.

Instead of this approach, governors could apply for waivers to shift Medicaid funds into programs that screen for and address root causes of health through hospitals and doctor’s offices. These programs could yield significant cost savings while improving health, instead of cutting coverage.

Reshuffling insurance coverage schemes as a way to reduce costs is basically a shell game — a dangerous one — that does little to address the core ills of the system. It would be a wasted opportunity if health care reform did not also transform the way we deliver health care so Americans can have better health at lower cost.