Policies That Limit Emergency Department Visits and Reimbursements Undermine the Emergency Care System

Maria C. Raven
2018 JAMA Network Open  
Emergency department (ED) visit rates in the United States have been rising over the past 2 decades, outpacing population growth. 1 These visits are portrayed in the lay press as unnecessary visits that must be reduced or avoided. Yet a growing body of evidence indicates that most ED visits are medically necessary and that EDs serve as a critical source of care for high-risk patients, including those with comorbid mental health diagnoses, substance use disorders, and poor social determinants of
more » ... ial determinants of health. Insurance companies and other payers have a years-long history of attempting to dissuade individuals from using the ED by refusing to pay for their visits-after the visit occurs-if it is categorized as nonemergent. In 2012, the Washington State Health Care Authority attempted to pass legislation stating they would only pay for ED visits for Medicaid patients that they deemed to be medically necessary. More recently, the health insurer Anthem implemented a similar policy, evaluated by Chou et al. 2 Their study examines this policy, which denies payments for ED visits based on a patient's discharge diagnosis. At first glance, this idea makes sense: no one wants to pay for an ailment that could have been treated in a less expensive setting. However, policies that deny payments based on discharge diagnosis put vulnerable patients at risk and have significant flaws. First, there is no way to make an accurate determination of medical necessity for emergency care in advance. In a previous study, 3 my colleagues and I examined whether a patient's symptoms at presentation to the ED could be labeled reliably as a nonemergency based on the discharge diagnosis-the diagnosis that Anthem is currently using to determine medical necessity. We found it was impossible. We restricted our analysis to include only discharge diagnoses that were categorized as nonemergent or primary care-treatable. 3 We linked this group of nonemergency diagnoses back to their corresponding chief concerns from when the patient had arrived at the ED. When we examined the universe of outcomes related to these chief concerns, we found 12.5% of patients with these presenting concerns required admission to the hospital (including the intensive care unit), and 3.4% went directly to the operating room. As emergency clinicians, we wait until after a workup to assign a discharge diagnosis: this workup is based on a detailed history and often involves blood work, imaging, and multiple hours of observation. That the same presenting symptoms that resulted in some patients going to the intensive care unit and others being denied coverage because the visit was considered unnecessary makes clear the impossibility of patients judging medical necessity. While few would argue that some proportion of patients who visit the ED could in theory be cared for in other settings, several recent studies have shown that most patients who seek care in the ED have urgent concerns. 4 Their decision to come to the ED is rational. It is clear (even by Anthem's own estimates) that the vast majority of ED visits are not unnecessary. Other studies have shown that individuals feel ED-based care is of higher quality and that a wider variety of services are more accessible. 5 The nation's primary care system is overstretched: outside of a few contained systems (eg, Kaiser) most primary care systems are unable to meet patients' need for timely care. And an additional force is at work that deserves more attention: outpatient clinicians are referring their patients into EDs at high rates. Our recent study 6 found that about 25% of US adults with 1 or more ED visit in the previous year had been referred to the ED by an outpatient clinician. Primary care +
doi:10.1001/jamanetworkopen.2018.3728 fatcat:c5bnxp5t2rfenazxk7al25vkzu