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June 8, 2017

Anthem won't cover some avoidable ED visits, sparking debate

Daily Briefing

Anthem has begun notifying hospitals, members, and state officials in  Georgia and Missouri that as of July 1, it will no longer cover ED visits for most instances of minor conditions that could "safely [be] treated in less acute facilities."

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Insurer aims to curb unnecessary ED use

According to Jay Moore, CMO for Anthem Blue Cross Blue Shield (BCBS) Missouri, the policy has long been part of coverage contracts, although it has not always been enforced. The insurer decided to begin enforcing the policy, Moore said, to stem increasing costs related to inappropriate ED use. "We've had an increase over time in [ED] utilization rates, and we have been working on trying to reverse that trend," he said.

And Debbie Diamond, a spokesperson for Anthem's BCBS of Georgia, added that while the insurer is trying to cut back on inappropriate ED usage, the decision to enforce the policy is not designed "to discourage somebody with an emergency condition who needs to go to an [ED] to go there." Rather, "it's a way to make sure that people are getting quality and affordable care," she said.

Anthem already enforces the policy in Virginia and Kentucky, and ED usage rates have dropped in those states, the St. Louis Post-Dispatch reports.

Policy details

In its notification, the insurer defines an "emergency" or "emergency medical condition" as "a medical or behavioral health condition of recent onset and sufficient severity ... that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that not getting immediate medical care could result in:

  1. Placing the patient's health or the health of another person in serious danger or, for a pregnant woman, placing the woman's health or the health of her unborn child in serious danger;
  2. Serious impairment to bodily functions; or
  3. Serious dysfunction of any bodily organ or part."

Anthem listed several conditions as examples, including chest pain, seizures, stroke, poisoning, "serious breathing problems," severe cuts or burns, and uncontrolled bleeding, among others.

Anthem said patients seeking care whose condition does not qualify as an emergency should instead contact their personal physicians, head to an urgent care clinic, or access BCBS' 24-hour online medical service, LiveHealth Online.

The ED policy does not apply if:

  • The patient is 13 years old or younger;
  • The patient was directed to the ED by a physician;
  • An urgent care center is not within 15 miles of the patient; and/or
  • The visit occurs on a Sunday or major holiday.

According to the Atlanta Journal-Constitution, the insurer said a panel of physicians will make the final assessment in individual cases as to whether an individual reasonably sought care at an ED.

Announcement sparks debate

Providers and patients have expressed mixed reactions toward the announcement, the Journal-Constitution reports.

For instance, Dave Dillon, spokesperson for the Missouri Hospital Association, explained that while "inappropriate [ED] use drives up cost for all and leads to overcrowding, ... not every venue of care is available 24/7, and not every Missourian is in a position to judge whether they are having a heart attack or acid reflux, which can mimic a heart attack."

Donald Palmisano, president of the Medical Association of Georgia, voiced similar concerns. He outlined a hypothetical situation in which a patient experiencing chest pains might go to the ED, learn he has indigestion, and so opt to stay home the next time he experiences similar symptoms—even though that next time, he might actually be having a heart attack.

"That's where our physicians are concerned," Palmisano said. "Because ... you're [telling] the patient, who doesn't have the clinical background, to determine whether their condition is of an emergency nature."

Citing a similar scenario, Becky Parker, president of the American College of Emergency Physicians, added, "I don't know and [the patient doesn't] know if that is a heart attack, a blood clot, or a collapsed lung unless I see you in the [ED]."

But state Rep. Terry England (R) said the insurer is "trying to change habits and get people to focus on going to their physician and not to the ED." He added, "It may be one of the few ways that you actually are able to maintain hospitals and keep the doors of hospitals open across the state."

Similarly, Jason Hockenberry, who teaches health policy at Emory University, said ED overuse "is a real problem. [EDs] are expensive; they're there for a different reason [than treating non-emergency conditions]. Blue Cross is clearly staking a claim here that we're going to try to change patient behavior."

And Jeff Fusile, president of BCBS of Georgia, pointed out that the insurer will have a panel of physicians review claims that are unclear. "There are lots of gray areas where the diagnosis wasn't so bad after all," he said, "but you have to look at the situation the person was in at the time they were in it" (Hart, Atlanta Journal-Constitution, 5/31; Bandlamudi, WABE, 5/31; Fox, NBC News, 6/5; Liss, St. Louis Post-Dispatch, 5/5).

A rare move

Rachel Sokol, a practice manager with Advisory Board's Health Plan Advisory Council, tells the Daily Briefing that it's uncommon for insurers to deny coverage for avoidable ED visits. More often, she said, insurers charge a high copay of $50 to $100 or more to discourage ED use—although that has had minimal success, and ED use is a major and rising cost for insurers.

Sokol added that insurers have been more successful communicating the availability of primary care providers, urgent care facilities, and other ED alternatives to members, with some even placing staff in the ED to educate members who have non-emergent cases about other places they can receive care.

"As ED costs continue to rise," Sokol said, "we expect to see insurers use all the tools available to them—including denying coverage in certain cases—to encourage appropriate utilization. We've seen plans 'gold card' providers who rarely have prior authorization requests denied and could imagine a similar scenario for individual members."

Access the new finance leader's resource guide

Leaders in Congress and the Trump Administration are reassessing their approach to repealing and replacing the Affordable Care Act. No matter the outcome, one thing is for sure: there will be serious and long-lasting financial consequences for hospitals.

This guide is intended to help you and your finance teams operate in this uncertain time. Inside, you'll find the information and no-regrets strategies needed to support mission and margin in any regulatory environment.

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