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Anthem’s imprudent standard

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It is well known that absent a very knobbly boot on the neck, health insurance companies behave like libertarian sadists on a coke binge. For example, Anthem continues to roll out its Diagnose Yourself or Pay policy, even though it violates federal law.

Alison Wrenne was home cooking breakfast for her two children last summer, when pain in her abdomen became so severe, she fell to the floor. “Just instantly, I was in really horrific pain all in my abdomen,” she explained to WKYT’s Miranda Combs. She thought she was going to pass out.

Her husband came home and after waiting to see if the pain would subside, they were told by a physician’s assistant friend that she should go on to the emergency room. Wrenne had an ultrasound to confirm that it was an ovarian cyst that had ruptured. It was not life-threatening, but her doctor assured her there was no way for her to know that.

“A couple of months later, I got a bill from the hospital and a letter from Anthem saying they had rejected my claim and that I should [not] have sought the emergency room and that I should have visited my local practitioner,” Wrenne said. She owed more than $4000.

Obviously Ms. Wrenne should have used her in-home ultrasound unit to diagnose the cause of her pain and determined that her condition did not meet Anthem’s definition of an emergency.

Just kidding. Anthem isn’t sharing the list of final diagnoses that justify a trip to the ER. This isn’t surprising, because telling patients don’t go to the ER if you have This Symptom could result in a nasty lawsuit. But it further highlights the sheer clusterfuckery of this policy.

There’s no way or a patient to know – for example – if her right lower quadrant abdominal pain is a ruptured ovarian cyst, which is not an emergency, or an ovarian torsion, which will earn the proud owner a quick trip to the OR for emergency surgery.

And patients aren’t the only people who can’t make such a determination based solely on such a symptom. Physicians, nurse practitioners, and physician assistants can’t do it either. The human body can be remarkably uncooperative when it comes to explaining what the hell is wrong with it, and it can be impossible to diagnose a problem unless a professional gets a chance to prod the patient.

Anthem claims that its policy is designed to discourage customers who have very mild conditions from going to the hospital and hanging out in an emergency department for ages when they could go to an urgent care center, or their primary care provider, or just stay at home and groan a lot.

Anthem tells WKYT’s Miranda Combs that the company is simply trying to cut back on care that is not normally perceived as an emergency such as “itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal”.

“Emergency rooms treat life and limb threatening situations, and if a member feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care.

I am sure that there are people who have insurance and go to the ER for things that no reasonable person would consider an emergency. After all, we live in a world with Bronies and bird watcher egg collectors. However, I am equally sure those people are rare enough that they aren’t making a dimple in Anthem’s bottom line. This assumption is supported by a study of ER visits conducted in 2013.

There is nearly a 90-percent overlap in symptoms between emergencies and non-emergencies, according to a 2013 study in the Journal of the American Medical Association.

This study was conducted after several states began to enact laws that would stick Medicaid patients with the cost of an ER visit if it turned out the patient wasn’t having a medical emergency. Zero surprise that legislators tried pulling this stunt on the poor. And doubtless this was the inspiration for Anthem’s policy, which now seeks to try it on people who are poorer than members of its C-suite, even though the study showed it is a stupid policy.

Patients present to the ED with chief complaints, symptoms, and signs, but not with discharge diagnoses. For a list of ED discharge diagnoses to be considered a nonemergency, the ED discharge diagnoses must be predictable based on chief complaint information available at triage. Our study illustrates the challenges of mapping from discharge diagnosis to chief complaint.

Although only 6.3% of ED visits had primary care–treatable discharge diagnoses, the chief complaints reported for these visits encompassed 88.7% of all ED visits. If a triage nurse were to redirect patients away from the ED based on nonemergency complaints, 93% of the redirected ED visits would not have had primary care–treatable diagnoses.

Anthem’s policy also violates federal law, according to the American College of Emergency Physicians.

“The ‘prudent layperson standard’ is federal law and requires health insurance companies to cover emergencies visits based on the patient’s symptoms, not the final diagnoses. No insurance policy is affordable if it abandons you in an emergency.”

The company is using secret lists of pre-determined diagnoses — which Anthem BCBS considers to be “non-urgent” — that may not be covered if the patient goes to the emergency department. In Missouri, the original list of nearly 2,000 diagnoses included “influenza,” — which has killed several people this season — “ovarian cyst” and “blood in the urine,” which can be symptoms of medical emergencies.

Sen. McCaskill is on the case in Missouri, but anyone who is covered by Anthem should drop their congresscritter a preemptive line. Be sure to pass along the link to the video. It features doctors behaving goofily and will frighten your elected representatives into doing what you want.

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