Sunday, March 4, 2018

Insurance Company Denial of Emergency Care

We live in an era of demonization.  Political adversaries are not opponents, they are villains.  Commentary that contrasts with our views is labeled ‘fake news’.   Presumption of innocence?  R.I.P.  Civil discourse has become a quaint memory.  Why would one debate respectfully when today’s tactic is to talk over and demean your adversary? 

On the morning that I prepared this post, I read an article reporting that one of Ohio’s largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms  (ERs).   In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack.   I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers.  An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided.

I felt that the journalist did not adequately present the insurance company’s motive and point of view.
Of course, I expect true emergency care to be covered.  And, I do not expect ordinary folks to reliably distinguish between a medical nuisance and an emergency.  Patients are not doctors. But, there should be some standard in place.  There should be a version of a reasonable person’s belief that an emergency is present. 

Insurance Companies are Easy Targets

Consider the following points.

  • Insurance companies are businesses and must be run responsibly, just like your business and my medical practice.  You may believe you are entitled to every imaginable medical benefit, but someone has to pay for it.
  • Many emergency room visits are clearly for non-emergent reasons.  This wastes health care dollars, leads to medical overutilization and clogs up emergency departments.
  • Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere. 
  • A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician’s office without an improved outcome. 
  • Do we expect an insurance company to pay for an ER visit for a splinter?
  • Do we expect an insurance company to pay for an ER visit to evaluate a child’s cold?
  • If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?
  • What would our position on this issue be if we were insurance company administrators?
I read (but cannot verify) that $40 billion are spent each year in this country on unnecessary ER care. Do you think there might be a better use for these funds?

It’s easy to vilify corporate America.  The pharmaceutical and insurance industries have large targets on their backs.  But, just because we can hit the target easily, doesn’t mean that our aim is true.


  1. Full disclosure, I'm a ER physician in California.

    First, as you are aware, by law (EMTALA) everybody who goes to an ER is entitled a medical screening examination (MSE) to determine if there is an emergency medical condition. That MSE can take 30 seconds or can take 6 hours and include labs, xrays, and CTs.

    Second, there are studies that the collective cohort of pts who show up at the ER have worse outcomes than who show up at outpatient offices. This type of acuity is also true when comparing inpatients to ER, and ICU to inpatients.

    Now...I agree with some of your points. Namely "Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere." Makes sense. Especially if a prudent layperson believes your ingrown toenail or runny nose could have been seen at an Urgent Care or outpatient office.

    Also agree with "Do we expect an insurance company to pay for an ER visit for a splinter?" and "Do we expect an insurance company to pay for an ER visit to evaluate a child’s cold?" and generally agree with "If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?"

    Now I disagree with, and challenge you to actually provide data to your point of "A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician’s office without an improved outcome." Especially with respect to "without improved income." ER docs do tend to workup more, but we are charged with finding emergencies.

    For instance, what would you do in the following cases?

    1. A 42 yo man comes to you with intermittent stomach distress for the past 2 days. Physical exam is normal.

    2. A 36 yo woman with a history of self-diagnosed migraines comes to you with a headache that is like her previous ones, however this one has been going on for 5 extra days. No fever.

    3. A 27 yo woman comes to the ED with dysuria for 2 weeks, and has been on 2 different antibiotics during that time with no relief.

    Overuse of the ER is a problem, albeit not a big one when comparing dollar utilization in our $3.0T US health care budget. ER overuse is multifactorial:

    1. People want relief NOW and an answer to their problem NOW. This used to not be the case 30 years ago. Nowadays, people don't want to wait a week when they have a symptom. They want to be seen NOW. People say "I called my doctor and they didn't have an appointment today, so I came here." Or they come after work.

    2. People don't know what symptoms are serious and which ones are not. And because of #1 above, they come to the ER.

    3. Their PMDs or RN's over the phone tell them to.

    4. They can get tests like labs and imaging done right away.

    5. For some people, ER visits are free because they are on state medicare. They don't even pay a co-pay. Think about the abuse!

    I think that is legislators and health care officials want to reduce ER utilization then we need to do any or all of the following: enact a co-pay on every visit even if you are homeless (lots of homeless people have cellphones!). I believe if you see a doctor you should pay something, even if it's $10. Healthcare is not free and it's common knowledge that people abuse free stuff. Another would be to increase the amount of primary care physicians, and train them to do simple procedures like I&D abscesses, pelvic exams. And lastly change tort reform. For some reason it's OK if their PMD missed an MI, but it's not OK if an ER doc misses one.

    Thanks for your blog. I read it regularly, often want to respond to but generally don't find the time or forget to.

    Oh yea, the answers to the diagnoses of the patients I listed above, and I had all of these in the past 6 months:
    1. STEMI w/ 99% proximal LAD
    2. Aseptic Meningitis
    3. PID

  2. First, let me express my gratitude to the thoughtful and contemplative ER physician who has decided to protect his or her identify.

    I confess that I do not have data to support my claim that more intensive ER evaluations do not lead to an improved medical outcome. More accurately, this statement is my opinion, the result of nearly 3 decades of medical practice.

    Anonymous has proffered some patient profiles of serious conditions that can masquerade as more innocent conditions. I believe his/her point is that we must be cautious before dismissing a ‘non-emergent’ case which in actuality might be a heart attack or meningitis. We must be careful, however, not to allow anecdotes to determine overall medical policy. Yes, a case of hiccoughs might be the result of a sub-hepatic abscess, but would you suggest that every case of hiccoughs I see be sent for a CAT scan so as not to miss an abscess?

    I do not follow your point that “it’s OK if their primary missed an MI, but it’s not OK if an ER do misses one.” Why should there be a different standard of care in the ER than in my office? All of us are not charged to be perfect and infallible. We are committed to being diligent, conscientious and reasonable. I completely agree with you that ER evaluations are much more intensive than those done for the exact same complaints for patients seen in physicians’ office. I don’t understand why an excellent ER physician feels that more testing needs to be done so as not to miss an emergent condition. Explain why a primary care physician should feel differently?

    When I see a patient with seemingly non-cardiac chest pain in my office, I respond accordingly. In the ER, this patient may very well trip the chest pain algorithm.
    Missing an emergent condition is not tantamount to medical negligence (although I am well acquainted with how plaintiff’s attorneys act upon such an event and how this might influence medical decision making. I refer you to the Legal Quality category.)

    If your care is diligent and your documentation supports your medical advice, and you have arranged for proper follow up, then you have done your job. I feel that the intensity of care for the same medical complaints should be similar regardless of the medical venue. Other ER physicians disagree and have expressed vociferous disagreement with me on this blog.

    Overutilization burns up health care dollars and generates zillions of false positive or incidentalomas which create new cascades of medical chaos that torment patients, their families and us.

    My post tomorrow will offer some additional points this issue and I hope that you will review.

  3. I've been an MD ER physician for almost 8 years and don't have a good answer to why some physicians are "more allowed" to miss an emergency than others. I honestly don't understand why a PCP approaches chest pain differently than an ER doc.

    I will say that I spent 4 years learning "emergency" medicine. Not "internal" medicine. Just think what that means. Everyday during residency when I had chest pain or abdominal pain come through that door, that person could be dying. That is the way I was taught.

    Maybe there is thought that ER training is broken.

    Yet every ER doc can recall *countless* patient encounters where the outpatient doc missed something critical, or didn't take a patient complaint seriously. Rarely happens the other way around.

    Less so with GI or Cardiology or Neurology because those patients, by the time they reach you, are usually differentiated with diagnoses.

    The bigger question is explaining why there is wide variability for a physical complaint among ER practicioners. I bet you do certain things in your practice for a GI complaint that other GI doctors do not, and vice versa. But perhaps in your field there is a relatively narrow amount of variability. I find in ER medicine there is wide variability. For instance just about every kid who comes into my ED with a cough in the winter season gets a CXR. I'm probably the only doc who orders that test very rarely. I don't know why they order more. Perhaps it's because I trained to hardly ever order CXRs for well-appearing cough in pediatrics because I learned at a quarternary childrens hospital for the handful of Pediatric EM rotations during my residency.

    I think the times that I read your insightful, interesting, and at times humorous blog and become angry are when you suggest that a big problem with our medical industry is when ER doctors do too much workup for a cough or a stomach ache. That's not where the money savings lie. $40 billion sounds like a lot of money. It is a lot of money. But it's only ~2% of the US health care budget.

    Have you ever in your professional career told someone to go to the ER because you were on call, got a phone call at night from a patient who you know whom is having worsening abd pain? (I am 100% certain in your 3 decades of service that the answer is "yes".) Maybe they have Crohns, and the pt is saying "this is my Crohns and it's getting worse." What do you want an ER doctor to do? Just give them morphine? Am I just available 24-7 just to give out morphine? This kind of thing happens every single shift. The patient gets a workup.

  4. Thanks again, @anonymous, for your thoughtful comment. I surmise that you practice your specialty with similar care. It seems that we largely agree. My point, which you seem to agree with, is that there is too much variability among physicians and venues for the exact same complaint. Examining the reasons underlying this is a necessary first step in addressing an endemic challenge of our profession - overdiagnoisis and overtreatment.

    I hope to see you again soon in this space.