Delivery of Care/Opinion

The high cost of denying payments for ER care

UnitedHealthcare puts its plans to deny some emergency room claims on hold – for now

Photo by Stephanie Ewens

Dr. Elizabeth Goldberg, M.D.

By Elizabeth Goldberg, M.D.
Posted 7/19/21
Outrage by emergency physicians over a proposed policy by UnitedHealthcare to stop paying for some emergency room claims has resulted in the policy being put on hold.
In all the data collection based on claims data, is there anyone tracking how many claims are denied? Does there need to be new OHIC regulations around insurance policies for emergency room care in Rhode Island? What are the opportunities to invest in programs such as “Pay for Success” developed by Dr. Annie De Groot and Clinica Esperanza to create primary care options for uninsured patients, instead of going to the emergency room? [See link below to ConvergenceRI story, “The coming health care revolt.”] How will the new 10-year plan for health in Rhode Island respond to such insurance policy challenges in its bid to make Rhode Island the healthiest state in the nation?
The state is still in the midst of recovery from the coronavirus pandemic, but it is unclear what the health insurance industry has learned from the experience, given UnitedHealthcare’s proposed new policy that sought to penalize patients going to the emergency room if the original presenting information did not match the resulting diagnosis. A bigger question to answer by regulators would be: what is the value of co-pays within the overall system of care? How much do co-pays affect the revenue stream of health insurers, given that it is drug costs, not utilization, that is driving higher medical costs in Rhode Island?
Another big question to ask, particularly with the proposed merger of Care New England, Lifespan, and Brown now on the table, is this: how much is attached to every hospital bill for facility fees?

PROVIDENCE – She arrived breathless and pale. For weeks she thought she was having indigestion; several times a day chest pressure gripped her when she was trying to work, garden, and lately even while sitting and watching TV.

The Tums didn’t seem to be helping, and so when her boss at work asked what was wrong and then directed her to the hospital, she didn’t protest.

Quickly my emergency physician colleague at the nearby community hospital realized this wasn’t “just” indigestion. Her cardiac enzymes returned elevated, and she received an urgent cardiac catheterization at our tertiary care center.

Recognizing what is wrong
These stories aren’t unique. Most people, whether health literate or not, can’t be aware of all the symptoms and signs of life-threatening health conditions. My patient was in higher education and had a clean bill of health. She thought this couldn’t possibly be serious.

This is why my colleagues and I specialize in emergency medicine and spend three to four years – and at least 10,000 hours, often more – learning how to distinguish between the serious and not-so-serious illnesses.

Heartburn can – like in my patient – be a critical occlusion of your coronary [heart] vessels. When these vessels remain blocked – because you may have waited at home - part of your heart muscle dies and you may never fully recover, developing heart failure.

Headaches can be benign or due to aneurysms that have ruptured in the brain. A “minor rash” can be from flesh-eating bacteria and can rapidly progress causing irreversible tissue damage. Delaying surgery portends death.

What is urgent?
So, when UnitedHealthcare recently revealed a new policy that denies payment of emergency department claims that they retrospectively determined were not urgent [once a skilled emergency clinician completed a full evaluation and made a diagnosis], many of us were outraged.

Are we going to ask every layperson to become expert diagnosticians and decide for themselves if their condition was dangerous? Likely not.

The truth is that most of the time a headache is just a headache. But, even brain aneurysm pain can be improved with ibuprofen, and it takes an expert to pick the “needle out of the haystack” and say – this is the person that needs imaging and a lumbar puncture.

Of concern, the patients that are the most price sensitive – unpaid caregivers for adults, Black and Hispanic adults, people with disabilities – will be the most likely to put off care, exacerbating already poor health outcomes in these groups.

To be sure, other countries get better value for their GDP spent on health care. We have to look critically at how to reduce costs in health care.

The high cost of deferring care
Perhaps, we can start by reclaiming some of the health profits and savings UnitedHealthcare made when people deferred necessary care during the biggest public health emergency of our time.

Or, we can be more thoughtful about approving drugs with little benefit, concerning risk profiles, and outrageous price tags, such as the new dementia drug Aducanumab.

But, if you ask any clinician who has practiced in the emergency room for more than a few weeks, they will tell you patients can’t always make their own diagnosis. If they could, we wouldn’t need hospitals staffed by highly trained emergency physicians and specialists on call.

For now, thanks to public outcry, UnitedHealthcare has agreed to delay their plan to deny coverage for some ER visits, but we expect they’ll reintroduce the policy when the pandemic is over. Our goal should be to get every American high-quality care and find smart ways to bend the cost curve, without expecting patients to be doctors.

Dr. Elizabeth Goldberg, M.D., is an emergency medicine physician in Rhode Island.


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