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The HMO Debate: Who Decides Emergency Care?

Jul 14, 1999 | CNN

Delores and Maurice Leatherberry have had their share of run-ins with their HMO, the latest coming this week when Maurice, 28, suffered a seizure. His wife took him to a hospital without receiving prior approval from their insurance company.

"I did not speak to them since I've been here," Delores told CNN. "I don't even know if (the hospital has) contacted them. I don't even know if they're going to pay for this."

It happened before, when her son needed emergency room care. "They sent me a bill saying I was not given approval, so I owe them," she said.

Having heard similar complaints about coverage under health maintenance organizations, Congress is working on a remedy. Democrats and Republicans even agree on what to call it a patients' bill of rights. But that's where the similarity ends.

Patient vs. payer

At issue: Who decides when an emergency room visit is medically necessary -- the patient or an insurance company?

Congressional members agree that Americans need a patients' bill of rights, but they disagree on the terms. Many physicians believe insured Americans are increasingly becoming victims of economic triage.

Patients may receive the urgent care they need, says Dr. John Graneto, an emergency room physician, only to go through an even more traumatic experience afterward fighting with their insurance company.

In the patients' bill of rights debate, Democrats want what they call a "prudent layperson" standard one that allows the patient, not the payer, to decide when an emergency exists.

The patient, in this case, is the "prudent layperson."

The proposal calls for the elimination of prior approvals and would require HMOs to pay for any necessary follow-up treatment.

HMOs challenged on compliance

Already in effect for Medicare/Medicaid recipients and federal employees, the "prudent layperson" standard is also the law in 28 states.

Dolores Leatherberry: 'I don't even know if they are going to pay for this'
But compliance has been spotty:

The insurance commissioner in Washington state is in the process of settling a case with health insurers who ignored the law and denied claims.

New York had a similar case where the state's attorney general subpoenaed HMOs accused of telling members they needed prior approval before emergency room visits.

"The unfettered use of the emergency room services without some kind of clinical protocol, or oversight would be a major step back," argues Patrick Hays of Blue Cross-Blue Shield.

Study: HMO instructions confusing

HMO instructions on emergency care can vary considerably, can be vague and may even be misleading, according to the results of a recent study.

Keith William Neely, a Ph.D. candidate in the Oregon Health Sciences University Department of Emergency Medicine in Portland, and his department colleague, Dr. Robert Louis Norton, analyzed membership manuals from 15 different HMOs.

Among the findings:

While most of the plans had written instructions explicitly advising members to call 911 in an emergency or go to an emergency department immediately, four of the plans had no mention of calling 911 or going immediately to an emergency room.

Three of the plans discouraged members from using the emergency room, stating that emergency departments are often overused, which increases health care costs for everyone and makes it difficult for emergency physicians to treat ''true'' emergencies.

Nine of the 15 HMOs called on members to distinguish between an ``emergency and urgent condition.'' This could lead some participants to call their HMO before seeking immediate help in an emergency, Neely said.

Most plans failed to include chest pain or symptoms of stroke in their definition of an emergency.

The study was published in the July issue of the Annals of Emergency Medicine.

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