Med community slams ER plan

May 12, 2018 GMT

Dr. Peter Jacoby has worked in emergency medicine for decades, and still doesn’t always know whether a patient is seriously ill as soon as he sees him or her.

“Just recently I had someone come in, writhing with belly pain that turned out to be nothing,” said Jacoby, chairman of the emergency department at St. Mary’s Hospital in Waterbury and chairman of the National Emergency Medicine Political Action Committee.

On the other had, he’s had people come to the ER with seemingly mild symptoms who end up having a serious illness. “You never know what you’re getting when people come in,” Jacoby said.

And if he can’t instantly diagnose how serious an ailment is, there’s no way a layperson can be expected to do that, he said.

Thus, Jacoby is deeply disturbed by Anthem Blue Cross Blue Shield’s “avoidable ER program,” which permits the company to deny coverage for non-emergency care received in an emergency department.


The program officially launched in 2017 and is now in six states, but not Connecticut.

Under the policy, an Anthem medical director will review claim information and medical records of most patients who receive non-emergency care in an ER. An Anthem spokesperson said claims are reviewed using the “prudent layperson standard.”

In other words, Anthem determines “whether a person with average knowledge of health and medicine would reasonably consider themselves to be experiencing an emergency medical condition.”

The Anthem statement on its policy said the company has worked with four board-certified emergency doctors to develop a list of non-emergency conditions that shouldn’t be treated in an ER.

The list includes athletes foot, common cold symptoms, suture removal and seasonal allergies. According to the company, each state can take the list and decide which conditions to include based on the market’s ER use patterns.

There are some patients to whom Anthem won’t deny coverage for emergency treatment of non-emergency ailments, including those who were directed to the emergency room by a provider, those younger than 15 and those who live more than 15 miles from an urgent care center.

“Anthem has, and will continue to make, enhancements to our ER program to ensure effective implementation,” the company’s statement reads.

State concerned

Anthem’s ER program has been “paused” in Connecticut, but no one could elaborate further on what that meant, except to say it’s not active in the state, according to state officials. Spokespeople from Anthem and the Connecticut Hospital Association also wouldn’t give details.

Even though the policy isn’t live in Connecticut, it’s still a source of concern to Jacoby and others in the state who are alarmed by the dangerous precedent it might set. Jacoby said a program like this could prevent people who need emergency help from seeking it.


“People are going to wait longer and longer to come in, and we’re going to have some bad outcomes,” he said. “(Anthem) shouldn’t be allowed to do this.”

Several hospitals wouldn’t comment on the avoidable ER program, including those represented by the Yale New Haven Health System, which includes Yale New Haven Hospital, Bridgeport Hospital and Greenwich Hospital. But the Connecticut Hospital Association, which represents the state’s hospitals and health-related organizations, has expressed concern about the existence of the program.

“CHA and its member hospitals want patients to seek care in the right setting, which is not always the emergency department. At the same time, patients should not be discouraged by the threat of non-coverage from seeking emergency care when they genuinely believe it is needed,” said Karen Buckley, vice president of advocacy for the hospital association.

Reversing a trend

According to a statement from Anthem, the goal of the program is “to encourage consumers to receive care in the most appropriate setting” and to “reduce the trend in recent years of inappropriate use of ER for non-emergencies.”

The Centers for Disease Control and Prevention, reports that, in 2015, the most recent year for which numbers were available, there were 136.9 million visits to emergency rooms in the United States. Of those, 12.3 million resulted in hospital admission and 1.5 million resulted in admission to the critical care unit.

A report released earlier this year by the non-profit Health Care Cost Institute showed the average price of an emergency room visit rose to $1,917 in 2016 from $1,458 in 2012 .

“If a consumer feels he or she has an emergency, they should always call 911 or go to the ER,” the Anthem statement reads. “But for non-emergency health care needs, ERs are often a time-consuming place to receive care, and, in many instances, 10 times higher in cost than urgent care.”

Though urgent care costs vary, most sources put the average cost of a visit somewhere between $100 and $200.

Onus on consumers

However, Jacoby said the Anthem policy puts undue pressure on patients. “We’re telling the public, when you go to a emergency room, you better be right,” he said.

The policy has raised the ire of many medical professionals, including those represented by the American College of Emergency Physicians, the national medical specialty society representing emergency medicine. The college’s leadership argued that the policy is requiring laypeople to make medical decisions they aren’t qualified to make.

The college has released two videos criticizing the policy. One shows a man with stomach pains searching his symptoms online. When his wife urges him to go to the ER, he replies that, if his pains turn out not to be serious, Anthem could stick him with the whole bill.

The other features a man at the gym who is having chest pains. When he is told to go to the ER, he, too, bemoans the Anthem policy.

Both ads end with a black screen bearing the message “Does your insurance company give you the benefit of the doubt if you think you’re having a medical emergency?”