Patients enrolled in Kaiser Permanente in Denver don't have to second-guess whether their medical emergencies are severe enough to be covered by their health plan.
Since last year, Kaiser Permanente's plans in California, Colorado, the District of Columbia, Hawaii and Maryland and have adopted a new model--the "prudent layperson" standard--to determine coverage for care given in emergency departments. The model was developed in collaboration with the American College of Emergency Physicians.
"We allow our enrollees to make their own decisions about whether their injuries or ailments require emergency care," says John P. Pappas Jr., M.D., associate medical director for operations of Kaiser's Rocky Mountain division.
"It costs a little more, and there are more visits," Pappas says. "But we save money on specialists and primary care. There is no question it is best for patients."
Emergency medical care is the focus of a bill before Congress--the Access to Emergency Medical Services Act--which mimics the Kaiser model in part. The bill, also known as the Cardin bill after its main sponsor Rep. Benjamin Cardin (D-Md.), would require HMOs and health plans to pay for a patient's emergency care if a prudent layperson would believe the condition merits such care. The legislation is co-sponsored by 134 other members of Congress.
"It is important that consumers have trust in the healthcare delivery system," says Patricia Lynch, a Kaiser public policy attorney. "When you feel like you are going to die, you shouldn't have to worry about finances."
During the past three years, the American College of Emergency Physicians has tracked dozens of what it considers to have been legitimate emergency claims that were denied by HMOs or health plans.
One denial involved a 46-year-old woman who entered the emergency department at St. John Hospital and Medical Center in Detroit with severe chest pains. Despite aggressive treatment, she later died--while still in the emergency department--of cardiopulmonary arrest.
James M. Fox, M.D., St. John's vice chief of emergency medicine, says the woman's health plan denied the $1,200 claim for the services she received because she did not receive pre-authorization.
"There was no time for anyone to do anything but to try to save this poor young woman's life," Dr. Fox says.
In California during the past 10 years, managed care has imposed great changes on the practice of emergency medicine, says Larry Bedard, ACEP president and a partner with California Emergency Physicians of Oakland, a group with 40 hospitals under contract.
"Physicians have to adapt to the demands of managed care," Bedard says. "We (CEP) have developed practice parameters and our own physician-profiling system to monitor utilization. It helps us in a proactive way to improve quality and reduce costs."
Using a best-practice approach, CEP has developed 20 guidelines or parameters for such situations as sprained ankles, sore throats and chest pain as well as other ailments and injuries. "We have cut down 20% to 30% on X-rays and other tests," Bedard says. "Our patient satisfaction scores and quality have improved."
For education and contracting purposes, CEP has invested in a physician utilization information system. "It's a way to monitor how physicians are utilizing resources," Bedard says. "We work with our physicians to practice more efficiently."
Medical directors of large HMOs have three main complaints about emergency departments, says Marty Karpiel, president of Karpiel Associates, a Los Alamitos, Calif.-based emergency and ambulatory-care services consulting firm.
"Emergency departments are very expensive for urgent care, and emergency physicians are quick to admit they order excessive amounts of ancillary tests," Karpiel says. "(Now) emergency physicians have stepped to the plate to address these concerns."
For example, to reduce costs, hospitals have developed "fast-track" minor-care units within emergency departments and urgent-care programs. Under the fast-track system, triage nurses evaluate patients entering the emergency department and send those classified as nonemergency to an adjacent fast-track area.
Karpiel estimates that fewer than half of all hospitals have created a fast-track system.
Some hospitals also have established observation and chest pain units as a first step toward admission for patients with unclear symptoms, Karpiel says.
"Health plans are doing more education with patients to help them make better decisions about how to access a primary-care doctor when they face a medical emergency," says Liza Greenberg, director of medical affairs for the American Association of Health Plans.
"Emergency departments are being extremely collaborative with health plans to provide the best care," Greenberg says.
Another component of Kaiser's prudent layperson model and the Cardin bill is that health plans are required to pay for the care necessary to stabilize a patient. Then, once the patient is stable, the health plan has 30 minutes to approve or disapprove additional benefits.
Without such a system, a physician may complete services and discover afterward that the health plan does not authorize the treatment.
Greenberg says the notification time after stabilization is too short to make the system work. "The (30-minute time frame) is fairly restrictive," she says. "It may be hard for a plan to meet."
Pappas says the 30-minute time limit is long enough. "It works for us, he says, but you need to have the infrastructure--telephones, staff--in place to do it."
Kaiser also has a case-management system in place that involves having other hospitals transfer Kaiser enrollees to Kaiser hospitals once they have been stabilized.
"We save money and improve quality," Pappas says. "We have the medical records that give us the best information to conduct follow-up care without unnecessary utilization."
"With 300,000 patient visits a year, Kaiser saves an average of 30% of total ER expenditures each year with post-stabilization transfer agreements with neighboring hospitals," he says. In 1991, for example, Kaiser reduced the $10 million that would have been spent on emergency care by $3.5 million.
"This system can be implemented nationwide if there is cooperation between the emergency physicians, hospitals and health plans," Pappas says.
Jay Greene is a regular contributor to Modern Physician who is based in St. Paul, Minn., and who specializes in healthcare business issues.