Slightly Hazy: An Insurer’s Emergency Room Policy Draws Congressional Scrutiny

By Oliver Kim

Last year, I had the good fortune to present at the Petrie-Flom Center’s conference on transparency and I started with an anecdote about a congressman who decided to wait rather than take his son immediately to the emergency room after he injured himself. The congressman assumed his son only had a sprain, but he had actually broken his arm. So why the wait? Because of a difference in his co-pay. In an interview, the congressman argued for policies to push consumers to understand—and be exposed to— healthcare costs in order to make better decisions about their care: “Way too often, people pull out their insurance card and they say ‘I don’t know the difference or cost between an X-ray or an MRI or CT Scan.’ I might make a little different decision if I did know (what) some of those costs were and those costs came back to me.”

The congressman’s policy prescription is becoming reality: last year, the largest Blue Cross Blue Shield plan Anthem announced a new policy where it would deny coverage for care provided in an emergency room that was later deemed non-emergent (except in certain circumstances). It seems a far cry from simply charging an ER co-pay, but Anthem argues it has seen a rise in non-emergency care being provided in emergency rooms. How are patients supposed to know if the ache or pain they are experiencing is not an emergency? Apparently there is a spreadsheet of over 1,900 ailments that Anthem considers non-emergent.

Anthem’s policy has now become a federal case: on December 20, 2017, the ranking Democrat on the Government Affairs Committee requested emails, documents, and presentations shared among senior management that led to the ER policy. Her letter as well as providers’ complaints have questioned whether Anthem is violating the “prudent patient” standard, or judging a patient’s situation by the symptoms presented, not the final diagnosis.

As the congressman said, people will make different choices if they understand the cost, but is this policy making cost the driving factor for someone deciding whether to seek care or just ignore it? To help people make decisions based not on their health but on their costs, potentially leading to worse outcomes, the system needs to evolve to both present and educate people about options rather than an either/or proposition. In that vein, Anthem notes that it is making an effort to provide its customers with services like telemedicine as an alternative to a stop into the emergency room, and such efforts to provide greater access to primary care should be applauded. Indeed, 24/7 access to care is a key component of federal primary care demonstrations.

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