Welcome to brain Stuff from How Stuff Works, Hey, brain Stuff, Lauren Bogle bam here. Navigating the health care system is already pretty dicey, and a new program put forth by insurance giant Anthem is muddying the waters even more for some. Known as the Emergency Department Review, the company's program launched in teen with the intent of reducing unnecessary visits to the nation's emergency rooms. In and of itself, the idea isn't such a bad thing, since emergency departments are sometimes
ill used. Report found thirty eight billion dollars per year in wasteful spending thanks to emergency department over use. However, per Anthem's policy, if a person goes to the emergency department with symptoms or a condition that turns out to not be life threatening, they could wind up holding the bag for a whole lot of money. We spoke with
Christina Gaines, communications director for Anthem Incorporated, via email. She said if a consumer chooses to receive care for non emergency conditions at the emergency department, when a more appropriate setting is available, Anthem will request more information, including additional medical records from the hospital and a statement from the consumer as to why they went to the emergency department.
Then an anthem medical director will review the additional information using the Prudent lay Person standard, and the claim might be denied as not a covered service. In the event of consumers claim is denied, they have the right to appeal. Much of the controversy surrounding this program lies with that Prudent lay person standard, Gains mentioned. The standard was enacted by the US Congress back in with forty seven states
opting to work it into state law as well. It was done to add a layer of protection for healthcare consumers so they can seek care without working up a huge emergency department bill. We also spoke via email with Dr David Farcie, president of the American Academy of Emergency Medicine. He said the Prudent lay Person standard requires health insurance companies to cover visits based on the patient's symptoms, not
the final diagnosis. This means if a patient has chest pain but turns out to have a non urgent medical condition such as gastritis or muscular pain, the insurance company must still cover the visit. We have a duty to safeguard patients and cannot expect our patients who have little to no medical training to be doctors and know the difference between a minor or life and death medical condition. Anthem is forcing the patients to be doctors in completely
disregard federal and state laws to protect patients. Anyone who's ever been in a potential emergency situation knows that sometimes the most logical choice isn't always the most obvious. This is further convoluted by a health care system in which it's often difficult, if not impossible, for a person to see a primary care physician or specialist in a timely manner, hence emergency department visits that could have been handled elsewhere.
Such was nearly the case for nurse practitioner Amanda Gorman. She recalled, I was almost forced to go to the emergency room this week because of a kidney stone and couldn't get a new appointment with a urologist. Gorman is married to a physician and was trying to go to the hospital where her husband works. She said, so if we're having trouble navigating this, I can't badge of the
struggles for regular patients. Gorman ended up finding an appointment with an out of network specialist, potentially costly risk in itself. She estimated that it was about six times as expensive as an e R cope would have been, but she didn't want to deal with the hassle of an e R. Many emergency medicine experts don't mince words about the potentially
damaging effects of the plan. We spoke with Dr Ryan Stanton, a Lexington, Kentucky based emergency physician and spokesman for the American College of Emergency Physicians the a c e P. He said this will harm people and lead to injuries and deaths. The goal of this program is not the denials, it's about the fear people will be afraid to seek emergency care. A CEP feels this policy is incredibly dangerous and puts people at risk in the name of profits.
I've talked to a number of people that were denied, and the common theme is how upset they were, but more importantly, they are now afraid to go to the emergency department even if they feel they have an emergency. Many conditions present with similar symptoms, whether they wind up being benign or truly life threatening. Stanton said, chess pain can be a heart attack or heartburn. Abdominal pain can be a pendicitis or gas. A headache can be a
ruptured aneurysm or a hangover. The challenge with medicine is that it deals in shades of gray and rarely black or white. The key is that if you feel your life or health or at risk, go to the e ER. Not everyone thinks Anthem's program is completely off base, though. Lindsay Artola is a health policy expert with Sage Health Strategy who supports some type of penalty for unnecessary use
of the emergency department. She said via email, the emergency room is by far the most expensive way to get healthcare, and with the advent of urgent care centers, nurse triage lines, and other alternatives, it's a poor use of health system resources for folks to use the e R as a primary care office. I think a financial penalty for misuse of health system resources isn't necessarily a bad idea. So how bad is the problem of misusing the e R?
Statistics very widely? A study using data from e ER visits from two thousand five eleven found that only three point three percent of e R visit were avoidable, which is in line with the CDC statistic of five point five percent. Meanwhile, Truven Health Analytics, drawing on insurance claims data from said that seventy of e R visits were unnecessary and avoidable. Clearly, the word avoidable has different meanings
for different people. Anthem spokesperson Gains said consumers who reasonably believe that they are experiencing an emergency medical condition should always go to the emergency room or call nine one one. She points out that Anthem will always cover emergency department
visits under certain conditions. For example, if a consumer was directed to the emergency room by provider, including an ambulance provider, if the patient is under the age of fifteen, if the patient's home address is greater than fifteen miles from an urgent care center, if the visit occurred during off hours that's between eight p m Saturday and eight am Monday,
or on a major holiday. If the patient received surgery I V fluids, I V medications or an m R I or CT scan, or if the patient had conditions such as chess pain, difficulty breathing, convulsions, fainting, or was experiencing a drug overdose. Many of these exemptions were added in January eighteen after public objections to the original policy it gains. Adds that Anthem's Emergency Department program is currently in effect in five states Missouri, Georgia, Ohio, Kentucky, and Indiana,
with no current plans to extend its reach. Today's episode was written by Elliot Hoyt and produced by Tyler Clang for iHeart Media and How Stuff Works. For more on this and lots of other topics, visit our home planet, how stuff Works dot com.