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Speaker 1: Welcome to brain Stuff from How Stuff Works, Hey, brain Stuff,

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Speaker 1: Lauren Bogle bam here. Navigating the health care system is

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Speaker 1: already pretty dicey, and a new program put forth by

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Speaker 1: insurance giant Anthem is muddying the waters even more for some.

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Speaker 1: Known as the Emergency Department Review, the company's program launched

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Speaker 1: in teen with the intent of reducing unnecessary visits to

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Speaker 1: the nation's emergency rooms. In and of itself, the idea

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Speaker 1: isn't such a bad thing, since emergency departments are sometimes

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Speaker 1: ill used. Report found thirty eight billion dollars per year

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Speaker 1: in wasteful spending thanks to emergency department over use. However,

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Speaker 1: per Anthem's policy, if a person goes to the emergency

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Speaker 1: department with symptoms or a condition that turns out to

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Speaker 1: not be life threatening, they could wind up holding the

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Speaker 1: bag for a whole lot of money. We spoke with

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Speaker 1: Christina Gaines, communications director for Anthem Incorporated, via email. She

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Speaker 1: said if a consumer chooses to receive care for non

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Speaker 1: emergency conditions at the emergency department, when a more appropriate

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Speaker 1: setting is available, Anthem will request more information, including additional

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Speaker 1: medical records from the hospital and a statement from the

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Speaker 1: consumer as to why they went to the emergency department.

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Speaker 1: Then an anthem medical director will review the additional information

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Speaker 1: using the Prudent lay Person standard, and the claim might

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Speaker 1: be denied as not a covered service. In the event

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Speaker 1: of consumers claim is denied, they have the right to appeal.

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Speaker 1: Much of the controversy surrounding this program lies with that

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Speaker 1: Prudent lay person standard, Gains mentioned. The standard was enacted

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Speaker 1: by the US Congress back in with forty seven states

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Speaker 1: opting to work it into state law as well. It

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Speaker 1: was done to add a layer of protection for healthcare

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Speaker 1: consumers so they can seek care without working up a

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Speaker 1: huge emergency department bill. We also spoke via email with

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Speaker 1: Dr David Farcie, president of the American Academy of Emergency Medicine.

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Speaker 1: He said the Prudent lay Person standard requires health insurance

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Speaker 1: companies to cover visits based on the patient's symptoms, not

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Speaker 1: the final diagnosis. This means if a patient has chest

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Speaker 1: pain but turns out to have a non urgent medical

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Speaker 1: condition such as gastritis or muscular pain, the insurance company

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Speaker 1: must still cover the visit. We have a duty to

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Speaker 1: safeguard patients and cannot expect our patients who have little

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Speaker 1: to no medical training to be doctors and know the

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Speaker 1: difference between a minor or life and death medical condition.

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Speaker 1: Anthem is forcing the patients to be doctors in completely

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Speaker 1: disregard federal and state laws to protect patients. Anyone who's

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Speaker 1: ever been in a potential emergency situation knows that sometimes

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Speaker 1: the most logical choice isn't always the most obvious. This

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Speaker 1: is further convoluted by a health care system in which

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Speaker 1: it's often difficult, if not impossible, for a person to

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Speaker 1: see a primary care physician or specialist in a timely manner,

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Speaker 1: hence emergency department visits that could have been handled elsewhere.

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Speaker 1: Such was nearly the case for nurse practitioner Amanda Gorman.

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Speaker 1: She recalled, I was almost forced to go to the

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Speaker 1: emergency room this week because of a kidney stone and

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Speaker 1: couldn't get a new appointment with a urologist. Gorman is

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Speaker 1: married to a physician and was trying to go to

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Speaker 1: the hospital where her husband works. She said, so if

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Speaker 1: we're having trouble navigating this, I can't badge of the

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Speaker 1: struggles for regular patients. Gorman ended up finding an appointment

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Speaker 1: with an out of network specialist, potentially costly risk in itself.

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Speaker 1: She estimated that it was about six times as expensive

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Speaker 1: as an e R cope would have been, but she

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Speaker 1: didn't want to deal with the hassle of an e R.

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Speaker 1: Many emergency medicine experts don't mince words about the potentially

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Speaker 1: damaging effects of the plan. We spoke with Dr Ryan Stanton,

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Speaker 1: a Lexington, Kentucky based emergency physician and spokesman for the

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Speaker 1: American College of Emergency Physicians the a c e P.

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Speaker 1: He said this will harm people and lead to injuries

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Speaker 1: and deaths. The goal of this program is not the denials,

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Speaker 1: it's about the fear people will be afraid to seek

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Speaker 1: emergency care. A CEP feels this policy is incredibly dangerous

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Speaker 1: and puts people at risk in the name of profits.

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Speaker 1: I've talked to a number of people that were denied,

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Speaker 1: and the common theme is how upset they were, but

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Speaker 1: more importantly, they are now afraid to go to the

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Speaker 1: emergency department even if they feel they have an emergency.

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Speaker 1: Many conditions present with similar symptoms, whether they wind up

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Speaker 1: being benign or truly life threatening. Stanton said, chess pain

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Speaker 1: can be a heart attack or heartburn. Abdominal pain can

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Speaker 1: be a pendicitis or gas. A headache can be a

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Speaker 1: ruptured aneurysm or a hangover. The challenge with medicine is

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Speaker 1: that it deals in shades of gray and rarely black

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Speaker 1: or white. The key is that if you feel your

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Speaker 1: life or health or at risk, go to the e ER.

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Speaker 1: Not everyone thinks Anthem's program is completely off base, though.

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Speaker 1: Lindsay Artola is a health policy expert with Sage Health

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Speaker 1: Strategy who supports some type of penalty for unnecessary use

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Speaker 1: of the emergency department. She said via email, the emergency

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Speaker 1: room is by far the most expensive way to get healthcare,

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Speaker 1: and with the advent of urgent care centers, nurse triage lines,

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Speaker 1: and other alternatives, it's a poor use of health system

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Speaker 1: resources for folks to use the e R as a

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Speaker 1: primary care office. I think a financial penalty for misuse

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Speaker 1: of health system resources isn't necessarily a bad idea. So

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Speaker 1: how bad is the problem of misusing the e R?

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Speaker 1: Statistics very widely? A study using data from e ER

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Speaker 1: visits from two thousand five eleven found that only three

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Speaker 1: point three percent of e R visit were avoidable, which

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Speaker 1: is in line with the CDC statistic of five point

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Speaker 1: five percent. Meanwhile, Truven Health Analytics, drawing on insurance claims

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Speaker 1: data from said that seventy of e R visits were

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Speaker 1: unnecessary and avoidable. Clearly, the word avoidable has different meanings

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Speaker 1: for different people. Anthem spokesperson Gains said consumers who reasonably

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Speaker 1: believe that they are experiencing an emergency medical condition should

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Speaker 1: always go to the emergency room or call nine one one.

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Speaker 1: She points out that Anthem will always cover emergency department

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Speaker 1: visits under certain conditions. For example, if a consumer was

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Speaker 1: directed to the emergency room by provider, including an ambulance provider,

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Speaker 1: if the patient is under the age of fifteen, if

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Speaker 1: the patient's home address is greater than fifteen miles from

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Speaker 1: an urgent care center, if the visit occurred during off

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Speaker 1: hours that's between eight p m Saturday and eight am Monday,

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Speaker 1: or on a major holiday. If the patient received surgery

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Speaker 1: I V fluids, I V medications or an m R

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Speaker 1: I or CT scan, or if the patient had conditions

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Speaker 1: such as chess pain, difficulty breathing, convulsions, fainting, or was

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Speaker 1: experiencing a drug overdose. Many of these exemptions were added

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Speaker 1: in January eighteen after public objections to the original policy

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Speaker 1: it gains. Adds that Anthem's Emergency Department program is currently

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Speaker 1: in effect in five states Missouri, Georgia, Ohio, Kentucky, and Indiana,

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Speaker 1: with no current plans to extend its reach. Today's episode

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Speaker 1: was written by Elliot Hoyt and produced by Tyler Clang

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Speaker 1: for iHeart Media and How Stuff Works. For more on

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Speaker 1: this and lots of other topics, visit our home planet,

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Speaker 1: how stuff Works dot com.