Insurers want to punish patients for contacting ambulance on trifles

Photo: depositphotos

Medical Insurance Company Anthem is the second largest insurance agent in the country, and its subsidiary Blue Cross and Blue Shield of Georgia told its customers that if they were in an emergency room with a problem that does not fall under the definition of an emergency, their insurance claim would not be met.

As columnist Michael Hiltzik writes for the Los Angeles Times, it's yet another ploy to keep customers from going to the ER for trivial reasons. But experts say the subsidiary Anthem plays with fire. It encourages patients to carry out self-diagnosis, and this can lead to irreparable consequences for human health.

“Patients do not come with a sticker on their forehead with a diagnosis written on it. As physicians, we can't always tell the difference between an emergency visit and a non-emergency one,” says Renee Sia of the Institute for Health Policy Research at the University of California, San Francisco.

Blue Cross Blue Shield of Georgia, the only insurer offering individual insurance plans in 96 from 159 state districts, sent letters to its customers at the end of May with a warning that from July 1 it would stop covering visits to emergency points in non-emergency situations.

The company defines emergencies as those that “a reasonable layperson with average knowledge of medicine and health would consider necessary for immediate treatment.” Other situations are not considered emergencies. They want patients who don't have dangerous symptoms to seek care from their primary care physician instead of the emergency room.

The principle “prudent layperson”Was introduced into the insurance industry to protect patients, and not to force them to conduct preliminary self-diagnostics. The idea was to require the insurers to calculate their payments depending on how the person himself identified the emergency, and not on the final diagnosis of the doctors. However politics Blue Cross Blue Shield of Georgia allowed the insurer to decide on the satisfaction of the claim itself after receiving evidence of the patient’s prudent actions and that the latter needed emergency assistance.

Insurer's spokesman Cross Blue Shield of Georgia Debbie Diamond explained that the goal of the company's new policy is to control costs and direct patients away from expensive departments and emergency clinics, and into more appropriate places for treatment.

“People present with a mild cold or routinely use the emergency room as their primary place of care. This must stop. This is a problem that prevents people from receiving truly accessible emergency care,” she said.

Diamond noted that this policy will not apply to patients under the age of 14. According to her, Anthem plans to implement a similar policy in New York, Missouri and Kentucky. It is not yet known whether the company plans to apply this policy in other states. Note that the insurance company provides its services in 14 states, including California.

Insurers and government agencies have been thinking for many years about how to stop the flow of calls to emergency rooms without urgent need. For example, insurance company Washington medicaid developed a list of 500 diagnoses that do not justify visiting emergency points. For such applications, they will not pay insurance amounts.

But doctors claimed that many of the symptoms on the list, such as headaches, ear pain and bronchitis, can be indicators of really serious diseases. Bronchitis, for example, often cannot be distinguished from pneumonia without a chest radiograph. Headaches can be symptoms of meningitis, encephalitis, or hemorrhage.

Governor Christine Gregoire canceled the plan in 2012, the day he was to take effect. Subsequently, Washington established a program that encourages hospitals to develop more effective systems for cutting off unnecessary visits, partly by educating patients and identifying frequent visitors or patients who visit the hospital mainly to get drugs.

Research Hsiapublished last year in a magazine American medical assn., showed that doctors and nurses in hospitals often could not distinguish urgent from non-urgent visits, glaring at the patient. Six of the top ten reasons for unnecessary visits, including abdominal, back and chest pain, sore throat and headaches, were also among the most frequent symptoms in 10 in truly emergency situations.

Many patients whose diagnoses were subsequently not considered urgent were transported by ambulance and provided emergency care, the study says. “Everyone who works in the emergency room or insurance has stories of completely inappropriate calls,” says David Anderson, an insurance expert at Duke University.

“The problem is that the decision to go to the emergency room is usually made uninformed. Most people know that something is wrong, and they don't know whether it's something urgent or not particularly serious. It is not known exactly how much money could be saved if such cases were dealt with more actively. A patient visiting the hospital for no reason is a caricature and is relatively rare,” said Ari Friedman, a physician who collaborated on the study. Hsia.

Policies aimed at reducing unnecessary visits are based on assessments made after definitive diagnoses that patients cannot make without a doctor's help. According to Friedman, emergency department services account for only 2% to 6% of total health care spending in the United States. “And most of the funds go to the sick, not the healthy.”

Hsia believes that the company Blue Cross and Blue Shield of Georgia pursues “well-intentioned policies with dangerous consequences for patients.” Research has shown that using financial incentives to reduce health care services often results in patients stopping seeking both non-urgent and emergency care. This was found in a classic study Rand Corp. in the 1970s, which found that patients required to pay health insurance were indeed less likely to use health care than those who received free services, with "utilization of both high- and low-impact services declining by roughly equal amounts." degrees."

Diamond notes that company patients Blue Cross and Blue Shield of Georgia have access to e-health services via smartphones and other connected gadgets, which allows them to remotely understand their symptoms.

But there are doubts how much this practice completely replaces the on-site visit to the emergency room. First, not all patients will have access to smartphones or to the network. Secondly, in cases where even specially trained nurses cannot perfectly judge the urgency of the help the patient needs while looking at him, a telephone consultation may not be very reliable.

As noted by Hsiasimilar subsidiary policy Anthem explainable from an economic point of view. But enterprises Anthem chose a rough and counterproductive way to cut costs, placing the responsibility to determine the severity of their condition on patients. At the same time, patients risk hundreds of dollars or even large amounts. If this is the world of future health, this is a dangerous and expensive place.

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