Going forward, if any of the 70 million UHC members make a request for a visit to the emergency department, the UHC will carefully consider the health issues that led to the visit, the “intensity of the visit”. diagnostic services performed ”in the emergency department (ED) and some context of the visit, such as underlying limb health problems and external circumstances. If UHC decides that the medical situation does not constitute an emergency, it will not provide “no coverage or limited coverage”, depending on the member’s specific insurance plan.
Emergency doctors and hospitals quickly reprimanded the plan. They say it sets a dangerous precedent by forcing patients to assess their own medical issues before seeking emergency care, which could end up delaying or preventing critical and even life-saving treatment.
The policy was originally scheduled to go into effect on July 1. But in an email to Ars on Thursday, UHC now says it is delaying the rollout amid criticism, at least until the pandemic is over.
“Based on feedback from our supplier partners and discussions with medical companies, we have decided to delay the implementation of our emergency service policy until at least the end of the national emergency period of public health, ”said a UHC representative in an email. “We will use this time to continue to educate consumers, clients and providers about the new policy and to help ensure that people visit an appropriate service site for non-urgent care needs.”
The delay is unlikely to allay critics’ concerns. After the policy was announced last week, doctors quickly noted that it was nearly impossible to assess the need for emergency care before it was actually provided. Many serious conditions have symptoms that overlap with non-serious conditions. For example, chest pain may just be a symptom of acid reflux or a panic attack, but it can also be a sign of a life-threatening heart attack. A bad headache could just be a bad headache, or it could signal a dangerous brain bleed.
In a 2018 analysis published in the JAMA Open Network, researchers found that up to 90% of symptoms that prompted an adult to go to the emergency room overlapped with symptoms of non-emergency conditions, which could be denied coverage. in the future. But those same symptoms could also be linked to life-threatening conditions.
This analysis was spurred on when the second largest insurance company, Anthem, instituted a policy similar to that of UHC and began denying ED coverage.
In an accompanying editorial, one of the review’s authors, Maria Raven, chief of emergency medicine at the University of California, San Francisco, emphasized how problematic it is to retroactively assess emergency medical care. “My colleagues and I examined whether a patient’s symptoms upon presentation to the emergency room could be reliably labeled as non-urgent based on the discharge diagnosis – the diagnosis Anthem currently uses to determine medical necessity.” , she wrote. “We found it was impossible. “
As emergency clinicians, we wait until the end of a work-up to establish a discharge diagnosis: this work-up is based on a detailed history and often involves blood tests, imaging and several hours of observation. The fact that the same symptoms that led some patients to go to the intensive care unit and others to be denied coverage because the visit was considered unnecessary clearly shows the inability of patients to judge. medical necessity.
In response to the planned UHC policy, Richard Pollack, president of the American Hospital Association, echoed Raven’s point. In a public letter to the CEO of UHC dated June 8, Pollack wrote that “patients are not medical experts and should not expect to self-diagnose while they believe they are. a medical emergency. Threatening patients with a financial penalty for making the wrong decision could act as a deterrent to seeking emergency care. “
Overall, Pollack said the AHA is “deeply concerned” about politics and urged the UHC to “reverse [it] at once. The American College of Emergency Physicians issued a similar response, saying the organization “strongly condemns” the UHC’s “dangerous decision”. Like the AHA, CAPE also noted that the policy may violate federal guarantees.
“CAPE strongly believes that the new policy is in direct violation of the Federal Prudent Layperson Standard, which requires insurance companies to provide emergency care coverage based on the symptoms that brought the patient to the service. emergency, not the final diagnosis, ”he added. the group of doctors said in a statement.
Before telling Ars that it had decided to delay the policy, UHC had justified its plan by saying it was an effort to cut health care costs.
In a statement to media outlet Fierce Healthcare, UHC wrote:
Unnecessary emergency room use costs nearly $ 32 billion a year, increasing healthcare costs for everyone. We are taking steps to make care more affordable, encouraging people who do not have a medical emergency to seek treatment in a more appropriate setting, such as an emergency care center.
Cost reduction measure
But the AHA and CAPE both backed down on this point, noting that there is little evidence to suggest widespread misuse of emergency services. The AHA also suggested that a better way to reduce the costs of emergency care might be to provide members with better access and coverage to elective care. Finally, the hospital association suggested that the financial argument was not strong coming from UHC, which reported huge profits amid the pandemic.
“Despite the implementation of policies to restrict enrollment coverage in recent years, UHC premiums continue to increase in most markets, as do UHC profits,” wrote AHA. “As you know, UHC’s parent company, UnitedHealth Group, reported a 35% year-over-year increase in operating profits in the first quarter of 2021. Despite gaining $ 6.7 billion in one quarter alone, UHC registrants are asked to pay more for their coverage. . “
UnitedHealthGroup also earned $ 6.6 billion in the second quarter of 2020, double what it earned in the same period the year before.
CAPE President Mark Rosenberg was cynical in his response to the planned UHC policy, saying in a statement: “While we are appalled by United’s decision, we are unfortunately not surprised. to see an insurance company try again to reduce its costs at the expense of necessary patient care.
“You are not going to pay”
For now, UHC members will be spared from reviewing emergency requests during the deployment timeframe. But even if the giant insurer never ends up implementing the policy, the damage may already be done. In 2018, after Anthem announced his similar policy to his members and started denying the claims, he received similar reactions and challenges. Anthem ended up rescinding the policy the same year and overturned the decisions when members challenged the claim denials.
Yet experts feared at the time that the mere announcement of the policy – not its implementation – would discourage some members from seeking treatment. Jonathan Kolstad, associate professor at the Haas School of Business at the University of California, Berkeley, told the New York Times in 2018: “You can get as much or more for your money by just telling people that you don’t. not go Pay. Even if, in the end, you pay.