Poll: 70% of Americans oppose efforts by insurance companies to deny payment for ER visits

Seventy percent of Americans oppose efforts by insurance companies to deny payment for emergency visits when patients believe they are having medical emergencies, but after examination are diagnosed with non-urgent medical conditions, according to the results of a new poll conducted by Harris Interactive on behalf of the American College of Emergency Physicians (ACEP).   In addition, 85 percent of respondents with regular medical providers who sought emergency care said they could not have waited to see their regular providers.      

"Many health plans and state Medicaid offices increasingly want to reduce costs by refusing or lowering payments for emergency room care, despite emergency care being only 2 percent of the nation's health care dollar," said David Seaberg, MD, FACEP, president of ACEP.  "This poll shows strong public support for emergency care and for a federal law already in place that protects coverage of ER visits.  It also shows that people are seeking emergency care because they believe they are having medical emergencies."

The federal law that protects coverage of emergency care is the prudent layperson standard, which requires health plans to cover visits to emergency departments based on an average person's belief that he or she may be suffering a medical emergency due to the person's symptoms, not the final diagnosis.  It was designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition.  It was included in the national health care reform law, the Patient Protection and Affordable Care Act in 2010 and the Medicare Balanced Budget Act of 1997. 

Private health plans, such as Blue Cross/Blue Shield and Univera in New York, have promoted misleading reports about emergency patients seeking care for nonurgent medical conditions. These flawed reports only look at final diagnoses — not the symptoms the patients came in with.  In addition, many health insurance plans communicate with their beneficiaries not to seek care unless they know they are having medical emergencies.  California, Iowa, New Hampshire, Tennessee, Washington and other states have been seeking to cut back on Medicaid emergency payments because of the state budget deficits brought on by the financial crisis.

"Patients should never be in the position of having to self-diagnose their own medical conditions out of fear their health plans won't pay," said Dr. Seaberg.  "Even a skilled physician does not know your diagnosis when you first walk in the door.  Emergency physicians are asking the public to sign a petition in support of protecting their coverage of emergency care."  

In Washington State, the state Medicaid office was set to implement a "zero tolerance" policy to deny payment for Medicaid emergency patients.  Denials would have been based on a list of 500 final diagnoses the state deemed to be non-urgent.  For example, a broken foot that turns out to be a sprain might not be covered by Medicaid.  After an outcry from physician and other groups, including ACEP and the Emergency Medicine Action Fund, Governor Chris Gregoire suspended the plan.

"We need to remain vigilant, but this was an important victory, not only for emergency patients in Washington state, but for everyone," said Dr. Wes Fields, chair of the Emergency Medicine Action Fund.   "Other states and health plans were watching closely to see what happened in that state." 

The Emergency Medicine Action Fund is a coalition of organizations, practitioners, and stakeholders created to respond to the challenge of health care reform across the acute care continuum.  Its contributors gave $100,000 to the Washington Chapter of ACEP for legal efforts and another $55,000 for policy analysis and health care research showing the HCA proposal would not have been safe for patients with a large number of urgent or emergent conditions.

"Fortunately, the prudent layperson standard survived this challenge and health plans are on notice that it is the law of the land," added Dr Seaberg.

Other poll findings:

• More than three-quarters (76 percent) said health insurance should pay for every emergency visits.
• More than half (51 percent) said they would be less likely to seek emergency care if they were told health insurance plans would not pay for emergency care if the patient had symptoms that they thought were serious or life-threatening but actually were not — and that the patient would be responsible for paying costs in full.
• Ninety percent of the public was surprised to learn that emergency care is just 2 percent of health care costs in the United States ($47.3 billion, according to government statistics — AHRQ 2008).  Only 4 percent recognized that emergency care is less than 5 percent of total health care costs.
• Sixty-three percent believe emergency care represents 26 to 75 percent of all health care costs.

"These results are informative to policymakers and anyone who incorrectly believe emergency departments are filled with non-urgent patients choosing to go to the emergency department out of convenience," said Dr. Seaberg. "People are coming because they need care."

Only 8 percent of emergency visits are for nonurgent medical conditions, according to the Centers for Disease Control and Prevention (CDC).  The CDC also says that "nonurgent" does not mean "unnecessary," because care is still needed within 2 to 24 hours.