Doctors and hospitals condemn the plans of UnitedHealthcare ̵
In the future, if one of the 70 million UHC members requests an emergency department visit, the UHC will carefully review what health issues have led to the visit, the “intensity of diagnostic services provided” in the emergency department (ED), and some context of the visit, such as the basic health conditions of the member and external circumstances. If the UHC decides that the medical situation is not an emergency, it will provide “no coverage or limited coverage”, depending on the member’s specific insurance plan.
Emergency doctors and hospitals quickly condemned the plan. They say it sets a dangerous precedent for requiring patients to assess their own medical problems before seeking emergency care, which can ultimately delay or prevent critical and even life-saving treatment.
The policy was originally due to take effect on July 1st. But in an email to Ars on Thursday, the UHC now says it is postponing launch amid criticism – at least until the end of the pandemic.
“Based on feedback from our provider providers and discussions with medical companies, we have decided to postpone the implementation of our emergency policy at least until the end of the national public health emergency period,” a UHC representative in Ars said in an email. “We will use this time to continue to educate consumers, customers and suppliers about the new policy and to ensure that people visit an appropriate emergency services site.”
The delay is unlikely to allay critics’ concerns. After the policy was first announced last week, doctors quickly realized that assessing the need for emergency care before it was actually provided was almost impossible. Many serious conditions have symptoms that overlap with non-serious conditions. For example, chest pain may simply be a symptom of acid reflux or a panic attack, but it may also be a sign of a life-threatening heart attack. A bad headache can simply be a bad headache or it can signal dangerous cerebral bleeding.
In a 2018 analysis published in the JAMA Open Network, researchers found that up to 90 percent of symptoms that prompt an adult to go to the emergency room overlap with symptoms of non-emergency conditions that may be denied coverage in the future. But these same symptoms can also be associated with life-threatening conditions.
This analysis was stimulated when the second largest insurance company, Hymn, created a similar UHC policy and began to refuse ED coverage.
In an accompanying edition, one of the authors of the analysis, Maria Raven, head of emergency medicine at the University of California, San Francisco, notes how problematic it is to evaluate emergency medical care retrospectively. “My colleagues and I have been investigating whether a patient’s symptoms when presenting in ED can be reliably labeled as non-urgent, based on the discharge diagnosis – the diagnosis that Anthem currently uses to determine medical need,” she wrote. “We found it impossible.”
As emergency clinicians, we wait until the end of working hours to make a discharge diagnosis: this treatment is based on a detailed history and often includes blood work, imaging and hours of observation. The fact that the same symptoms, as a result of which some patients go to the intensive care unit and others are denied coverage because the visit was considered unnecessary, clearly shows the inability of patients to assess medical necessity.
“I strongly condemn”
In response to UHC’s planned policy, Richard Pollack, president of the American Hospital Association, echoed Raven’s views. In a public letter to the UHC chief executive on June 8, Pollack wrote that “patients are not medical experts and should not be expected to self-diagnose during what they consider to be emergency medical care. Threatening patients with a financial penalty for making the wrong decision can have a chilling effect on seeking emergency care. “
In general, Pollack said the AHA was “deeply concerned” about the policy and called on the UHC to “reverse [it] immediately. “The U.S. College of Emergency Medicine has issued a similar response, saying the organization strongly condemns the UHC’s” dangerous decision. “Like the AHA, ACEP also noted that the policy could violate federal guarantees.
“ACEP strongly believes that the new police force is in direct violation of Prudent Layperson’s federal standard, which requires insurance companies to provide emergency care coverage based on the available symptoms that brought the patient to the emergency department, not the final diagnosis.” from doctors said in a statement.
Before telling Ars that it had decided to postpone the policy, UHC justified its plan by saying it was an attempt to reduce healthcare costs.
In a statement to the media Fierce Healthcare UHC wrote:
Excessive use of the emergency department costs nearly $ 32 billion a year, which increases the cost of health care for all. We are taking steps to make care more accessible by encouraging people who do not have emergency medical care to seek treatment in a more appropriate setting, such as an emergency center.
Cost reduction measure
But the AHA and ACEP rejected that point, noting that there was little evidence to suggest widespread misuse of emergency departments. The AHA also suggested that a better way to reduce emergency costs could be to provide better access to and coverage of non-emergency assistance to members. Finally, the hospital association suggested that the financial argument was not strong from the UHC, which reported profits from banners amid the pandemic.
“Despite policies to limit participant coverage over the past few years, UHC’s premiums continue to rise in most markets, as do UHC’s profits,” the AHA wrote. “As you know, the parent company of the UHC UnitedHealth Group reported a 35% annual jump in operating profits in the first quarter of 2021. Although they earned $ 6.7 billion in one quarter, UHC participants have to pay more for their coverage. “
UnitedHealthGroup also earned $ 6.6 billion in the second quarter of 2020, twice as much as it earned in the same period last year.
ACEP President Mark Rosenberg was cynical in his response to UHC’s planned policy, saying in a statement: “Although we are discouraged by United’s decision, we are not surprised to see that an insurance company is once again trying to reduce its costs. account of the necessary care for the patient. “
“You will not pay”
For now, UHC members will be spared from reviewing ED claims during the release delay. But even if the giant insurer never finishes setting the policy, the damage can already be done. In 2018, after Anthem announced a similar policy to its members and began to refuse requests, it received a similar response and challenges. The anthem finally effectively returned politics in the same year and reversed decisions when members challenged the waivers.
However, experts worried at the time that only announcing the policy, not implementing it, would discourage some members from seeking care. Jonathan Colstadt, an associate professor at the Haas School of Business at the University of California, Berkeley told The New York Times in 2018: “You can get so much or more money for your money frankly by just telling people you won’t go pay. Even at the end of the day to pay. “