Last month’s tragic shooting in Las Vegas shocked us all, but first responders and the medical community had prepared for such an event, and were able to save many lives due to their quick responses and training. Indeed, according to CBS News: “There was no shortage of heroes Sunday night at Sunrise Hospital, the closest trauma center to the Las Vegas Strip.”
Ask any doctor who works in emergency medicine; they will tell you they are there because they want to be on the frontlines of caring for others, often when patients and their families are experiencing the worst day of their lives. It is a heavy burden for emergency room doctors to take on this role, but one that we cherish because saving anyone’s life is a reward unto itself.
Yet, despite the privilege of being able to play such an important role in peoples’ lives, at the end of the day, health insurers disregard the value and the essential role emergency departments and emergency physicians play. As a business, health insurers often look for ways to increase their bottom line, even if that means denying people coverage for care in the emergency room.
In fact, in three states, including Georgia, health insurance giant Anthem Blue Cross Blue Shield is now warning policy holders that they may have to pay for their trips to the emergency room. If you hold a policy with Anthem and visit the ER, Anthem may refuse to pay if it disagrees with your decision to seek care. The company has even developed a secret list of diagnoses that they will not pay for, such as influenza (which 36,000 Americans die from every year) and blood in the urine.
Consider a patient with a severe headache, vision problems and numbness in one arm who is worried about a possible stroke. If it is a stroke, a delay of even minutes could mean permanent and severe loss of brain function or even death. But if properly treated, often they can resume their normal lives just hours after leaving the ER. Patients suffering a potential stroke should not delay a trip to the ER, wondering if Anthem will cover their visit.
What is so alarming about this new enforcement by Anthem is that it violates the prudent layperson standard — which is in the Affordable Care Act and in many state laws. The prudent layperson standard requires health insurance companies to cover emergency care based on a patient’s symptoms instead of the final diagnosis — that’s because there’s no way for a patient to know what’s causing their symptoms until they’ve sought care!
This Anthem policy is disturbing to me, and other ER doctors, because it will have a chilling effect on our patients and their willingness to seek emergency medical attention. Instead or rushing to an ER when they should, they may try to wait it out for fear of saddling their families with crushing hospital debt, because they are unsure their symptoms are caused by something that will end up meeting Anthem’s definition of an emergency. Anthem is essentially telling their policyholders that they need to know exactly what is wrong before they go to the emergency department. Frankly, it is the role of the emergency physician to determine whether one has an emergency condition or not. Patients should not be expected, nor asked to, diagnose themselves.
My organization recently took a poll of Americans and found that nearly 70 percent of respondents oppose Anthem’s policy to deny coverage for emergency care. More alarming, is that 43 percent of respondents reported that they delayed or avoided seeking emergency care in the past two years out of concerns about the cost of co-pays, co-insurance and deductibles. Nearly half said their medical conditions worsened as a result.
It is my hope that lawmakers and the media will learn about this new policy from Anthem, and tell the health insurer that this is not acceptable either morally or within the confines of the law. Patients suffering from potentially life threating conditions should immediately go to the ER, not delay — wondering if Anthem will cover their visit. Simply put, Anthem is jeopardizing people’s lives with this new policy and must immediately respect the prudent layperson standard.
John Rogers M.D., FACEP is president-elect of the American College of Emergency Physicians and the co-emergency department medical director at Coliseum Northside Hospital in Macon.