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January 2018 Advocacy Update - Defending Patients Against Anthem's Attacks
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4/19/2018 at 8:32:06 PM GMT
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January 2018 Advocacy Update - Defending Patients Against Anthem's Attacks

Defending Patients Against Anthem's Attacks on Access to Care

By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA

 

As you read in the President’s message this month, Anthem Blue Cross/Blue Shield has rolled out a new policy in upwards of 14 states, including Georgia, Ohio, and Kentucky, among others. Anthem’s policy forces patients to pay for any emergency department (ED) visit with a final diagnosis that Anthem deems to be non-urgent; a clear violation of the prudent layperson standard codified in federal law.  

 

This policy forces patients, not emergency physicians, to decide whether they are experiencing an emergency. A 2013 study in JAMA found a nearly 90 percent overlap in symptoms between emergencies and non-emergencies.1 There are even examples of claim denials for patients brought in by EMS. At least one patient in Missouri was transported by ambulance to the ED after a car accident and treated for minor injuries; Anthem denied her claim.

 

Thankfully, California ACEP sponsored legislation in the past to establish a robust prudent layperson standard in California that prevents Anthem from implementing this policy.

 

As Dr. Moulin outlined, in mid-December we learned of a new payment practice Anthem is planning to implement on January 1, 2018. Anthem plans on reimbursing ambulance transport providers for not transporting patients to the hospital. Because payment for non-transport financially incentivizes ambulance providers to avoid taking patients to the ED, without important consumer protections, this practice could lead to bad patient outcomes and predatory billing practices.

 

The consequences of this ambulance transport reimbursement policy are potentially serious for patient safety. As a result, we sent requests to the Department of Insurance and the Department of Managed Healthcare asking that they delay this change in reimbursement practice until there can be greater regulatory and public scrutiny.

 

We have a number of concerns with Anthem’s proposed California policy.

 

First, this creates a financial incentive to not provide healthcare to individuals who have called 911. There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories.2 That same study found that paramedics under triaged almost one in five patients. Under current practice, that under triage does not pose great patient risk because patients are transported to an ED where an emergency physician will examine them. Given the time for transport involved in most ambulance runs, as well as the burdens of wall time, this new reimbursement policy creates a strong incentive for non-transport, resulting in patient harm.

 

Second, patients with Medicare, Medicaid, the uninsured, the elderly, and the critically ill disproportionately rely on an ambulance transport to the ED.3 As a result, this policy will place these vulnerable populations at even greater risk.

 

Third, this has the potential to increase the patient’s out of pocket costs if they are required to pay their contractual share of cost for this “service” even if they refuse ambulance transport.

 

Finally, it is unclear if the ambulance transport providers would be held liable for any harm that resulted from their decision not to send a patient to an ED. If a patient is harmed, the law should be clear about who is liable.

 

We will pursue all available avenues to stop Anthem's attempts to deny patients access to emergency care. We will also be investigating potential changes to state law in order to protect patients from this dangerous policy.

 

We will pursue all available avenues to stop Anthem’s attempts to deny patients access to emergency care. California ACEP has always stood with patients against insurance company denials of care and will stand with them again.

 

REFERENCES  

 

  1. Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits. Jama. 2013;309(11):1145-1153.
  2. Neeki MM, Dong F, Avera L, et al. Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department. The western journal of emergency medicine. 2016;17(6):690-697.
  3. Squire B T, Tamayo A, Tamayo-Sarver, JH. At-Risk Populations and the Critically Ill Rely Disproportionately on Ambulance Transport to Emergency Departments. Annals of Emergency Medicine. 2010;56(4):341-347.


Kelsey McQuaid-Craig, MPA
Director of Policy and Programs
California ACEP


Last edited Thursday, April 19, 2018
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