Physicians protest harmful Anthem emergency care coverage policy

Andis Robeznieks
Senior Staff Writer
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A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

“Save the ER for emergencies—or you’ll be responsible for the cost,” states a notice the insurance company sent its enrollees in Missouri. “Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations. But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).”

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

“Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to Anthem President and CEO Joseph Swedish. “Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.”

Dr. Madara’s letter goes on to note that the policy also serves to reduce the value of health insurance purchased from Anthem, as once covered care for an emergency medical condition now “leaves patients potentially holding the bag for the cost of that care.”

The prudent layperson standard

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.

"This new policy will mean that patients experiencing emergencies will not go to the ER because of fear of a bill, and could die as a result," ACEP President Rebecca Parker, MD, said in a news release. "Health plans have a long history of not paying for emergency care. Now, they are trying to roll over federal law that emergency physicians fought for to protect patients from this 'profits first, people last' behavior by insurers."

The policy is in place in Georgia, Kentucky and Missouri, and will be implemented in Indiana starting Sept. 1. It was first rolled out in Kentucky in late 2015, and Anthem reports that only “around 1 percent” of ER claims have been denied for being an avoidable visit. That statistic does not capture patients who, due to the new policy, decided to avoid the emergency room even when their condition was emergent.

Basis for policy unclear

The MAG has been vocal on the matter, raising awareness and concerns about the claims-denial policy’s potential impact on patient care. The MAG called on Blue Cross Blue Shield of Georgia to publicly share the data behind the new approach to payment for emergency care.

“Every Georgian should be concerned about the effects of the new Blue Cross ER policy,” said MAG President Steven M. Walsh, MD, said. “Patients shouldn’t have to worry about conducting a self-diagnosis while wondering whether their insurer will cover the care they have paid for in the form of their premiums when they are in the middle of what they fear could be life-or-death medical emergency.”

Leaders from the Missouri State Medical Association, Missouri College of Emergency Physicians, Missouri Association of Osteopathic Physicians and Surgeons, and the Missouri Hospital Association recently sent a joint letter to the state’s insurance director to “express deep concern” about the Anthem policy.

“We think this policy is unfair to policyholders, and downright dangerous for patients,” they wrote in the letter.

A policy calling on the AMA to “work with state insurance regulators, insurance companies and other stakeholders to immediately take action to halt the implementation of policies that violate the ‘prudent layperson’ standard of determining when to seek emergency care,” was adopted at the 2017 AMA Annual Meeting by the AMA House of Delegates.

In his letter, Dr. Madara mentioned how the new policy specifically targeted Anthem’s policy and noted how “physicians’ testimony passionately focused on what will undoubtedly be its harmful impact on patients.”

“The AMA is committed to addressing health care costs and working with all stakeholders, including Anthem, to develop policies that improve the efficiency of our health care system and ensure that patients receive the right care at the right time,” Dr. Madara wrote. “However, policies that inappropriately shift costs onto patients are antithetical to these efforts. We find Anthem’s cost-shifting policy addressing emergency care to be objectionable and the likely consequences of its adoption to be harmful. As such, we ask that Anthem rescind this policy.”

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Oct 20, 2017
A decision by the New Jersey high court could affect 2,000 cases. It could also undermine patient-physician decision making and informed consent.