Speaker 1: Welcome to brain Stuff from How Stuff Works, Hey, brain Stuff,
Speaker 1: Lauren Bogle bam here. Navigating the health care system is
Speaker 1: already pretty dicey, and a new program put forth by
Speaker 1: insurance giant Anthem is muddying the waters even more for some.
Speaker 1: Known as the Emergency Department Review, the company's program launched
Speaker 1: in teen with the intent of reducing unnecessary visits to
Speaker 1: the nation's emergency rooms. In and of itself, the idea
Speaker 1: isn't such a bad thing, since emergency departments are sometimes
Speaker 1: ill used. Report found thirty eight billion dollars per year
Speaker 1: in wasteful spending thanks to emergency department over use. However,
Speaker 1: per Anthem's policy, if a person goes to the emergency
Speaker 1: department with symptoms or a condition that turns out to
Speaker 1: not be life threatening, they could wind up holding the
Speaker 1: bag for a whole lot of money. We spoke with
Speaker 1: Christina Gaines, communications director for Anthem Incorporated, via email. She
Speaker 1: said if a consumer chooses to receive care for non
Speaker 1: emergency conditions at the emergency department, when a more appropriate
Speaker 1: setting is available, Anthem will request more information, including additional
Speaker 1: medical records from the hospital and a statement from the
Speaker 1: consumer as to why they went to the emergency department.
Speaker 1: Then an anthem medical director will review the additional information
Speaker 1: using the Prudent lay Person standard, and the claim might
Speaker 1: be denied as not a covered service. In the event
Speaker 1: of consumers claim is denied, they have the right to appeal.
Speaker 1: Much of the controversy surrounding this program lies with that
Speaker 1: Prudent lay person standard, Gains mentioned. The standard was enacted
Speaker 1: by the US Congress back in with forty seven states
Speaker 1: opting to work it into state law as well. It
Speaker 1: was done to add a layer of protection for healthcare
Speaker 1: consumers so they can seek care without working up a
Speaker 1: huge emergency department bill. We also spoke via email with
Speaker 1: Dr David Farcie, president of the American Academy of Emergency Medicine.
Speaker 1: He said the Prudent lay Person standard requires health insurance
Speaker 1: companies to cover visits based on the patient's symptoms, not
Speaker 1: the final diagnosis. This means if a patient has chest
Speaker 1: pain but turns out to have a non urgent medical
Speaker 1: condition such as gastritis or muscular pain, the insurance company
Speaker 1: must still cover the visit. We have a duty to
Speaker 1: safeguard patients and cannot expect our patients who have little
Speaker 1: to no medical training to be doctors and know the
Speaker 1: difference between a minor or life and death medical condition.
Speaker 1: Anthem is forcing the patients to be doctors in completely
Speaker 1: disregard federal and state laws to protect patients. Anyone who's
Speaker 1: ever been in a potential emergency situation knows that sometimes
Speaker 1: the most logical choice isn't always the most obvious. This
Speaker 1: is further convoluted by a health care system in which
Speaker 1: it's often difficult, if not impossible, for a person to
Speaker 1: see a primary care physician or specialist in a timely manner,
Speaker 1: hence emergency department visits that could have been handled elsewhere.
Speaker 1: Such was nearly the case for nurse practitioner Amanda Gorman.
Speaker 1: She recalled, I was almost forced to go to the
Speaker 1: emergency room this week because of a kidney stone and
Speaker 1: couldn't get a new appointment with a urologist. Gorman is
Speaker 1: married to a physician and was trying to go to
Speaker 1: the hospital where her husband works. She said, so if
Speaker 1: we're having trouble navigating this, I can't badge of the
Speaker 1: struggles for regular patients. Gorman ended up finding an appointment
Speaker 1: with an out of network specialist, potentially costly risk in itself.
Speaker 1: She estimated that it was about six times as expensive
Speaker 1: as an e R cope would have been, but she
Speaker 1: didn't want to deal with the hassle of an e R.
Speaker 1: Many emergency medicine experts don't mince words about the potentially
Speaker 1: damaging effects of the plan. We spoke with Dr Ryan Stanton,
Speaker 1: a Lexington, Kentucky based emergency physician and spokesman for the
Speaker 1: American College of Emergency Physicians the a c e P.
Speaker 1: He said this will harm people and lead to injuries
Speaker 1: and deaths. The goal of this program is not the denials,
Speaker 1: it's about the fear people will be afraid to seek
Speaker 1: emergency care. A CEP feels this policy is incredibly dangerous
Speaker 1: and puts people at risk in the name of profits.
Speaker 1: I've talked to a number of people that were denied,
Speaker 1: and the common theme is how upset they were, but
Speaker 1: more importantly, they are now afraid to go to the
Speaker 1: emergency department even if they feel they have an emergency.
Speaker 1: Many conditions present with similar symptoms, whether they wind up
Speaker 1: being benign or truly life threatening. Stanton said, chess pain
Speaker 1: can be a heart attack or heartburn. Abdominal pain can
Speaker 1: be a pendicitis or gas. A headache can be a
Speaker 1: ruptured aneurysm or a hangover. The challenge with medicine is
Speaker 1: that it deals in shades of gray and rarely black
Speaker 1: or white. The key is that if you feel your
Speaker 1: life or health or at risk, go to the e ER.
Speaker 1: Not everyone thinks Anthem's program is completely off base, though.
Speaker 1: Lindsay Artola is a health policy expert with Sage Health
Speaker 1: Strategy who supports some type of penalty for unnecessary use
Speaker 1: of the emergency department. She said via email, the emergency
Speaker 1: room is by far the most expensive way to get healthcare,
Speaker 1: and with the advent of urgent care centers, nurse triage lines,
Speaker 1: and other alternatives, it's a poor use of health system
Speaker 1: resources for folks to use the e R as a
Speaker 1: primary care office. I think a financial penalty for misuse
Speaker 1: of health system resources isn't necessarily a bad idea. So
Speaker 1: how bad is the problem of misusing the e R?
Speaker 1: Statistics very widely? A study using data from e ER
Speaker 1: visits from two thousand five eleven found that only three
Speaker 1: point three percent of e R visit were avoidable, which
Speaker 1: is in line with the CDC statistic of five point
Speaker 1: five percent. Meanwhile, Truven Health Analytics, drawing on insurance claims
Speaker 1: data from said that seventy of e R visits were
Speaker 1: unnecessary and avoidable. Clearly, the word avoidable has different meanings
Speaker 1: for different people. Anthem spokesperson Gains said consumers who reasonably
Speaker 1: believe that they are experiencing an emergency medical condition should
Speaker 1: always go to the emergency room or call nine one one.
Speaker 1: She points out that Anthem will always cover emergency department
Speaker 1: visits under certain conditions. For example, if a consumer was
Speaker 1: directed to the emergency room by provider, including an ambulance provider,
Speaker 1: if the patient is under the age of fifteen, if
Speaker 1: the patient's home address is greater than fifteen miles from
Speaker 1: an urgent care center, if the visit occurred during off
Speaker 1: hours that's between eight p m Saturday and eight am Monday,
Speaker 1: or on a major holiday. If the patient received surgery
Speaker 1: I V fluids, I V medications or an m R
Speaker 1: I or CT scan, or if the patient had conditions
Speaker 1: such as chess pain, difficulty breathing, convulsions, fainting, or was
Speaker 1: experiencing a drug overdose. Many of these exemptions were added
Speaker 1: in January eighteen after public objections to the original policy
Speaker 1: it gains. Adds that Anthem's Emergency Department program is currently
Speaker 1: in effect in five states Missouri, Georgia, Ohio, Kentucky, and Indiana,
Speaker 1: with no current plans to extend its reach. Today's episode
Speaker 1: was written by Elliot Hoyt and produced by Tyler Clang
Speaker 1: for iHeart Media and How Stuff Works. For more on
Speaker 1: this and lots of other topics, visit our home planet,
Speaker 1: how stuff Works dot com.