Anthem Blue Cross Blue Shield changed its insurance policy, cutting back what it covers when patients go to the emergency room for non-emergency health problems, beginning in June 2017. So, clients may have to take a gamble: treat their health condition as an emergency or not. If they go to the ER and learn it was not an emergency, Anthem may not cover their client’s bill.
Dr. Jonathan Heidt, who specializes in emergency medicine at the University of Missouri Hospital and is also the president of the Missouri College of Emergency Physicians, has seen this new policy affect his own patients and hopes a better plan can be established.
Many state organizations are concerned that this policy may be adopted by other insurance companies in the United States, changing healthcare for more than just Anthem customers. Anthem has the second largest market share for health insurance companies in the US, according to Statista, an online database of statistics.
“One patient [who was insured by Anthem] had a stroke and thought that at the time the symptoms began it would go away if he just slept on it, and the next morning he'd be fine. It was not,” Heidt said. “So he came in over 24 hours out from his stroke and if he would have come in at the time his symptoms on sets, we may have been able to intervene.” But, concerned about costs, the patient didn’t go in.
Heidt said he thinks the problem will get worse if other companies follow Anthem’s lead.
He said he believes Missouri should develop a program similar to one implemented in Washington state for its Medicaid program. In 2013, the program “ER is for Emergencies” allowed doctors, patients and Medicaid representatives to work together to reduce unnecessary ER bills. In the first year, this program saved $33.6 million, according to The Washington State Hospital Association.
Heidt said the program focused on three main things:
-The program educated patients on when to go to the ER.
-It encouraged close follow-ups with primary care physicians after ER visits.
-It prioritized communication in emergency departments.
“So they were able to improve quality of care, while also saving resources,” Heidt said. “Which should be our ultimate goal. Instead of just putting down the sledgehammer of ‘We aren't going to see you in the ER because we think you are non-emergent.’”
The Missouri Hospital Association also does not approve of Anthem’s ER coverage policy. Missouri Hospital Association spokesperson Dave Dillon says the policy isn’t prioritizing its customers.
“What Anthem has [is] the benefit of hindsight, and can look at the diagnosis; whereas the patient is in the moment trying to make a decision about the care that they ultimately need,” said Dillon.
Anthem might be the leading commercial insurance company pushing this policy to control costs, but even the state has acknowledged the need for change too. State legislators are concerned by the “inappropriate use of hospital emergency departments by Medicaid enrollees,” according to Missouri’s 2017 legislative guide.
In response, an initiative called Low Acuity Non-Emergency, or LANE, was proposed because a considerable amount of people who benefit from Medicaid may visit the ER too often, stated in a press release from the Missouri College of Emergency Physicians, Missouri Hospital Association and Missouri State Medical Association. As of now, the program has not been implemented.
Dave Dillon, the vice president of public and media relations at the Missouri Hospital Association, says that hospitals and physicians will continue to collaborate with state officials to design a system that will reduce inappropriate emergency department encounters.
Heidt also explains that Anthem’s policy also puts hospitals in an uncomfortable position because they cannot turn away any patient that comes to the ER needing care. This is due to the Emergency Medical Treatment and Active Labor Act, which requires hospitals with an emergency department to provide appropriate care regardless of a patient’s finances.
Barry Chambers, the vice president of finance at Boone Hospital Center in Columbia, says that Anthem’s policy may cause other insurance companies to follow in their footsteps, thus changing hospital operations.
“Well the concern all hospitals have [is] will all insurance companies start to go that direction?” Chambers said. “So you know realistically hospitals would...probably have to shift a lot of their business to outpatient centers.”
Essentially, hospitals would have to build more stand-alone outpatient labs to accommodate the patients who will not go to the ER due to these insurance policies.
This policy is of concern for all hospitals, according to Chambers because it is ultimately less revenue for the hospitals.
Although people may feel powerless in this situation, Heidt suggests in the meantime that if Anthem’s patients are denied coverage, they should file an appeal with Anthem, the Department of Insurance and the Attorney General’s Office.
Currently Anthem is enforcing this ER policy in four states, but it might expand that to 10 other states in 2018.