Researchers at Brigham and Women's Hospital analyzed a national sample of Emergency Department visits between 2011-15 to determine what proportion of them could be denied coverage if commercial insurers across the U.S. adopted the policy of a large national insurer, Anthem, Inc., to potentially deny coverage, after the visit, based on ED discharge diagnoses.
Researchers studied visits by a population of over 28,000 commercially insured adults, aged 15-64, and found that the insurer's list of non-emergent diagnoses would classify coverage denial for 15.7 percent, or 4.6 million ED visits annually. Their findings will be published in the October 19 issue of JAMA Network Open.
"Up to one-sixth of adult emergency department patients with private health insurance would qualify for further review and may be denied coverage under this policy," said Shih-Chuan (Andrew) Chou, MD, MPH, attending physician in the Department of Emergency Medicine at the Brigham, and lead study author.
Researchers noted that in almost 90 percent of ED visits, the primary presenting symptoms that brought patients to the emergency department were the same presenting symptoms as those with diagnoses at risk of denial. Yet, among these patients, more than 65 percent received emergency-level services, such as imaging or multiple blood tests. Researchers concluded that using a diagnosis-based approach to retrospectively identify inappropriate visits as a means of determining coverage may be problematic because patients make reasonable decisions to go to the ED based on their symptoms.
"Nearly 90 percent of adult ED patients will have symptoms that may potentially lead to a non-emergency diagnosis, and review for possible coverage denial, including symptoms such as chest pain, which is one of the most common reasons patients are hospitalized from the ED," Chou said.
"Patients come to the ED with symptoms and not diagnoses," said Jeremiah D, Schuur, MD, MHS, emergency physician and health policy researcher at the Brigham, and senior author of the study. "After-the-fact policies that use final diagnoses to judge the appropriateness of an ED visit and further apply a financial penalty will put patients in a difficult spot where they are expected to self-determine whether there is a concerning illness or not. A better solution is to make it easier for patients to receive care for acute illnesses when they want to go outside the ED, for example, with urgent care centers."
###
Schuur and Chou report grants from the Emergency Medicine Foundation for unrelated work. Schuur reports receiving personal fees from the Emergency Foundation, and grant funding from the Center for Medicare and Medicaid Innovation for unrelated work. Schuur also serves on the Quality and Patient Safety Committee of the American College of Emergency Physicians.
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 3,000 researchers, including physician-investigators and renowned biomedical scientists and faculty supported by nearly $666 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.
Media Contact
Elaine St. Peter
[email protected]
617-525-6375
@BrighamWomens
http://www.brighamandwomens.org
