Tag Archives: Non-Emergent Diagnoses

Anthem ER policy could deny 1 in 6 visits if universally adopted, JAMA study warns

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https://www.healthcaredive.com/news/anthem-er-policy-could-deny-1-in-6-visits-if-universally-adopted-jama-stud/540241/

Dive Brief:

  • Anthem Blue Cross Blue Shield’s controversial policy that denies emergency coverage based on a patient’s diagnosis after a visit to the ER, would affect as many as one in six (15.7%) ER visits if adopted universally by commercial insurers, according to a new study from JAMA Network.  
  • Anthem’s policy is currently active in six states. In July, the American College of Emergency Physicians and the Medical Association of Georgia filed a federal lawsuit asserting that Anthem BCBS of Georgia is violating federal law requiring insurers to cover the costs of emergency care based on a patient’s symptoms rather than their final diagnosis.
  • “Our results demonstrate the inaccuracy of such a policy in identifying unnecessary emergency department visits,” Shih-Chuan Chou, lead author of the JAMA study, wrote. “This policy could place many patients who reasonably seek emergency care at risk of coverage denial.” 

Dive Insight:

As healthcare costs rise, insurers continue to seek ways to stem payments for emergency care, which hit their pockets the hardest. Anthem’s approach, taken in the summer of 2017, is to disincentivize what it deems to be unnecessary ER visits by denying coverage for patients with non-emergent ER discharge diagnoses. 

Earlier this year, UnitedHealth Group began reviewing ER claims with the most serious conditions in an effort to reduce or deny claims with improper evaluation and management codes. While similar in that they both crack down on ER visits, Anthem’s policy looks to move patients away from ERs and into less expensive urgent care centers and retail clinics, while UnitedHealth’s policy change is about making sure hospitals are billing properly.

The backlash has been much harsher for Anthem. According to a report issued this past July by Sen. Claire McCaskill, D-Mo., Anthem denied roughly 12,200, or 5.8%, of all emergency room claims in Missouri, Kentucky and Georgia from July 2017 to Dec. 2017 through this policy. Missouri’s hospital association was one of many health organizations to publicly oppose the policy.

In a statement to Healthcare Dive, Anthem defended its ER policy as a way to “ensure access to high quality, affordable healthcare” by encouraging consumers to receive care in “the most appropriate setting.” 

“If a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED,” the statement reads. “But for non-emergency health care needs, EDs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care.” 

 

 

Only 3.3% of ED Visits ‘Avoidable’

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http://www.healthleadersmedia.com/quality/only-33-ed-visits-avoidable?spMailingID=11851350&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1240385528&spReportId=MTI0MDM4NTUyOAS2

Image result for ED Visits

The top three non-emergent ER diagnoses were identified by researchers as joint disorders, atopic dermatitis, and other soft tissue diseases.

What does “avoidable” mean?

Answer: It depends on who’s doing the study.

A study published Thursday in the peer-reviewed International Journal for Quality in Health Care found that only 3.3% of emergency room visits could be classified as “avoidable.” That stands in stark contrast, for example, with another study from Truven Health Analytics that found nearly 71% of emergency room visits are avoidable. What gives?

For its part, the more recent study, Avoidable Emergency Department Visits: A Starting Point, contends that it’s difficult to determine whether an ED visit was necessary until after the visit, which makes some sense, but severely limits the ability of triage to make a difference.

“Using chief complaints derived from diagnoses, which are determined post hoc, can be dangerous because visits that are eventually determined to be non-emergent after physician examination and diagnostic testing are virtually indistinguishable from emergent visits,” the study says.

So there’s that.

The 3.3% of visits the study’s authors do contend are actually avoidable include visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home, which is fairly restrictive. Further, a significant number of those avoidable visits, by their definition, included mental health and dental conditions, which emergency departments are ill-equipped to treat.

“This suggests a lack of access to healthcare rather than intentional inappropriate use is driving many of these ‘avoidable’ visits,” said study author Renee Hsia, MD, of the Department of Emergency Medicine at the University of California, San Francisco, in a press release. “These patients come to the ER because they need help and literally have no place else to go.”

To derive their results, study authors examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

By contrast, a separate study, which used data from emergency department visits of patients with employer-sponsored health plans, and examined insurance claims data for more than 6.5 million emergency room visits made by commercially insured individuals, under age 65, in calendar year 2010, found that just 29% of those patients required immediate attention in the emergency room.

The Truven study found that the top three non-emergent diagnoses were joint disorders, atopic dermatitis, and other soft tissue diseases.

Part of the controversy surrounding ED visits is, unsurprisingly, about money. ED care is expensive compared to non-emergency settings, and not only do insurance companies have an incentive to reduce unnecessary visits in favor of lower-cost settings of care, but with the rise of high deductible health plans, so do many patients. That is especially true for patients with employer-sponsored high-deductible plans, where the patient is responsible for all medical care costs up to a certain deductible, usually several thousand dollars, in a calendar year.

Medicaid patients, to use one example, do not generally have the same cost-sharing responsibilities, although that is changing.