Providers were recently joined by two senators in pushing back on commercial health plan restrictions on nonurgent ED use. However, federal policy elsewhere is advancing ED payment restrictions.


April 23—Amid increasing efforts by private and public payers to rein in emergency department (ED) spending, recent federal data showed divergent trends between overall visits and nonurgent visits.

Hospital ED visits in 2015 declined by 3 percent to 136.9 million visits, from 141.4 million in 2014, according to recent data from the Centers for Disease Control and Prevention (CDC). That drop followed an 8 percent increase in ED use in the preceding year.

The CDC results differed from recent data from the Agency for Healthcare Research and Quality (AHRQ), which found that ED visit rates reached a 10-year high for all age groups in 2015. AHRQ also found a 3 percent increase the previous year.

The two federal agencies use differing sampling techniques to extrapolate national figures.

In contrast to its findings on overall ED utilization, CDC found the rate of “nonurgent” ED use increased from 4.3 percent of visits in 2014 to 5.5 percent of visits in 2015. The 2015 rate also was higher than the 2013 rate of 5 percent.

The agencies did not define nonurgent conditions but instead used hospital responses.

“Semiurgent” visits also increased as a share of all visits. They increased to 26.1 percent of visits in 2015 from 24.6 percent in 2014, according to CDC.

Provider Pushback

The American College of Emergency Physicians (ACEP), in a release on the latest ED utilization trends, highlighted the spread of insurer policies that deny coverage for care of nonemergency conditions.

"Your insurance company is legally required to cover your emergency visit based on your symptoms, not the final diagnosis," said Paul Kivela, MD, president of ACEP. "Insurance that abandons you in an emergency is no insurance at all. With nearly 90 percent of urgent and nonurgent symptoms overlapping, insurers should not leave patients to figure out themselves if their symptoms are truly life-threatening."

The highest-profile insurer to reject coverage of nonurgent symptoms is Anthem Blue Cross Blue Shield, which implemented such no-pay policies in Indiana, Georgia, Kentucky, Missouri, New Hampshire and Ohio.

Hospitals also have stepped up their pushback on Anthem’s expanding policy.

“Anthem’s retroactive determination of coverage for emergency services is both dangerous and out of compliance with the ‘prudent layperson’ standard,” seven hospital groups wrote the insurer in a March letter.

Under the federal EMTALA law, providers are required to screen and stabilize patients who have emergency medical conditions based on the “prudent layperson observer” standard.

The insurer’s policy runs counter to that standard by putting “the patient in the position of knowing their diagnosis before seeking care and the clinician in the position of both knowing that diagnosis and turning the patient away from the emergency room,” the hospital groups wrote.

The groups urged Anthem to drop the policy.

In previous responses, an Anthem spokeswoman said the policy was driven by increasing ED utilization for nonemergency care. She said claims for nonemergency care would be reviewed using the prudent layperson standard to determine whether a more appropriate setting—such as a primary care office, urgent care center, or the insurer’s 24-hour nurse hotline—was available.

EDs were responsible for 10 percent of the acute care that Americans received between 1996 and 2010, according to a study in the International Journal of Health Services. However, the extent to which EDs drive additional hospital spending was revealed by CDC data indicating that 14.8 million ED visits in 2015 led patients to be placed in observation status or to receive inpatient care.

The financial impact on hospitals from the spread of the Anthem policy was spelled out in a February report from Moody’s Investors Service, which concluded it could create “volume declines as well as further pressure on margins and cash flow.”

Specifically, hospitals likely will see fewer ED visits, lower revenue, and higher bad debt rates. Additionally, “physicians will see less reimbursement under the reduction in payment for certain same-day services,” Moody’s analysts wrote.

Divergent Federal Response

The provider concern with Anthem’s policy recently was echoed by federal lawmakers. Sens. Ben Cardin (D-Md.) and Claire McCaskill (D-Mo.) in March urged Health and Human Services Secretary Alex Azar II and Labor Secretary Alexander Acosta to review Anthem’s policy as a potential violation of consumer rights.

In a joint letter, the senators outlined how Anthem may have violated federal law by rejecting ED claims that should have been allowed under the prudent layperson standard, which is applicable in group health plans, plans offered in the individual and group markets, Medicare, and Medicaid managed care plans.

“Despite federal law, private insurers are once again using tactics to prevent people from seeking care in the emergency room,” the senators wrote. “[W]e remain concerned that Anthem’s ED policy still forces patients to determine, before they even leave their home, if their symptoms are serious enough to go to the emergency room.”

Although the Trump administration has not responded to the Anthem-specific concerns raised by the legislators, some critics said the administration’s Medicaid policies were allowing similar issues to develop in those programs. Following the Obama administration’s 2015 approval of an Indiana Medicaid requirement for enrollees to pay a higher copay for ED visits that the state determined were nonurgent, the Trump administration has approved such policies in other Medicaid programs.

Those policies came in response to rising ED utilization by Medicaid enrollees following the Affordable Care Act’s coverage expansion. For instance, the CDC found that in 2014, ED visits by beneficiaries in Medicaid and the Children’s Health Insurance Program (CHIP) increased by 25 percent, or more than 10 million.

However, the latest CDC data found a small pullback in 2015, with Medicaid and CHIP ED visits declining to 47.5 million from 49.3 million in 2014.

Meanwhile, concerns that many of the nearly 600 off-campus EDs are overpaid for the care they provide recently led Congress’s primary advisory body to recommend steep Medicare cuts to those EDs.

The Medicare Payment Advisory Commission (MedPAC) voted unanimously April 5 in favor of a recommendation that Congress cut Type A ED rates by 30 percent for off-campus stand-alone EDs that are within six miles of an on-campus hospital ED. The cut would affect about 75 percent of urban EDs, according to a five-market analysis by MedPAC staff, and would save Medicare between $50 million and $250 million.

Although federal legislators have yet to introduce any bills targeting payment policies for nonurgent care, a growing number of state bills have done so. For instance, Ohio Rep. Alicia Reece (D) introduced House Bill 536, which would outlaw Anthem's policy.

Additionally, several hospitals and health systems have challenged the Anthem ED payment policy in state court.

Moody’s noted that the range of pushback already has led Anthem to recently implement “some changes to this policy” while expanding “the types of ER visits that it will allow.”


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, April 24, 2018