Healthcare executives sent a letter to Missouri’s Insurance Director Chlora Lindley-Myers asking her to review Anthem’s emergency department (ED) policy of not covering emergency services it deems unnecessary in the state.
Anthem recently announced the new policy. The payer already has similar policies in Kentucky and Georgia and may expand to more states. Anthem reportedly notified the state insurance department before making the change.
The letter signed by Herb Kuhn, CEO of the Missouri Hospital Association; Dr. Jonathan Heidt, president of the Missouri College of Emergency Physicians; Brian Bowles, executive director of the Missouri Association of Osteopathic Physicians and Surgeons; and Thomas Holloway, executive vice president of the Missouri State Medical Association, said the “policy is unfair to policyholders, and downright dangerous for patients.”
The American College of Emergency Physicians (ACEP) and its Missouri chapter have called the policy a “clear violation of the national prudent layperson standard.” That standard requires payers to cover patients based on a patient’s symptoms and not their final diagnosis.
ACEP said nearly 2,000 non-urgent diagnoses on Anthem’s list of possibly non-covered symptoms can be life-threatening or lead to further health problems. However, Anthem said that only a small percentage of claims have been denied for unnecessary ED use in other states with the policy.
The reason for the policy change is the payer would prefer patients go to less expensive retails clinics and urgent care clinics and use 24/7 telehealth services if they can't see their physicians. While Anthem views the policy change as a way to save costs and cut ED visits and wait times, opponents to the plan say that it may cause people to delay needed care.
"If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance," said Dr. Rebecca Parker, president of ACEP. "The vast majority of emergency patients seek care appropriately, according to the CDC, and often times should have come to the ER sooner."
Payers view the more than 2,300 convenient care clinics in the U.S. as a way to contain healthcare costs. Retail clinics and urgent care clinics are seen as ways to control costs and reduce ED utilization, but the jury is still out as to whether they actually perform those benefits.
A study published last year in the Annals of Emergency Medicine found that, to date, retail clinics "have not been associated with a meaningful reduction in low-acuity ED visits."
Anthem, one of the largest payers in the country, stands behind its policy and other insurance companies are likely watching to see if the change leads to fewer ED visits and lower costs. If Anthem sees savings, more insurance companies may follow suit, which could lead to major changes in ED utilization and could result in more uncompensated care for hospitals.