M.D.Board Member, My Emergency + My Choice
How Texas Legislators are fighting to protect patients’ rights and access to life-saving emergency care | By Eric McLaughlin, M.D., Board Member, Texas Association of Freestanding Emergency Centers
When medical emergencies occur, unobstructed and convenient access to high-quality emergency care is the top priority. That’s not a privilege; it’s a basic healthcare right. Yet, Texas ranks 47th nationwide for access to emergency care and the state previously received an ‘F’ for this dismal distinction from the American College of Emergency Physicians.
Highly trained physicians are one of the most important elements of good emergency medical care. Patients trust physicians to evaluate, treat, advise, and cure them during medical emergencies. Yet, despite warnings from physician groups about our failing emergency healthcare network, Texans’ access to emergency care is increasingly under attack.
Recently, some of the largest insurance companies in Texas implemented potentially dangerous anti-ER care policies. These policies allow insurers to retroactively deny coverage for emergency medical services based on the final diagnosis instead of considering the original reason a patient seeks emergency care.
Consider two patients who go to the ER with similar chest pain. The ER physician’s level of concern, physical examination, and lab and radiology testing may be exactly the same for both. Ultimately, the workup might reveal that the true nature of one patient’s pains was indigestion. In the other, the physician might discover a heart attack or other life-threatening medical issue. The first patient receives tremendous reassurance from the ER visit, and might go on to alter their diet and take acid-reducing medication. The other receives life-saving medications, surgical interventions, and similar reassurance that they made the right choice to go to the ER.
Under these punitive insurance company policies, an insurer might deny the first patient’s claim because the final diagnosis was “indigestion” and not a life-threatening emergency. The costly ER visit could become a huge financial burden. Down the road, when patient one is still paying off their medical bills, if they have another bout of worrisome chest pain, will they think twice about going to the ER? The thought of additional financial hardship might influence them to make a very poor decision when a true medical emergency is lurking. Using financial pressure to dissuade a patient with a potential emergency from seeking immediate care is unethical, manipulative, and flat-out wrong.
The question “should I go to the ER or shouldn’t I” was addressed decades ago. To protect patients from insurance companies denying coverage for care, Congress enacted the Prudent Layperson Standard in 1997.
Leaders in Texas felt so strongly about enacting these patient protections, that the Legislature enacted this Prudent Layperson Standard definition in the same year through Senate Bill 385, Section 1301.155.
Texas ER physicians support the Prudent Layperson Standard. They will tell you, without hesitation, that unless they do a proper examination and medical work-up, even they can’t rely on symptoms alone to determine whether a patient is experiencing a true medical emergency. Studies in the Journal of the American Medical Association show a 90 percent overlap in the symptoms experienced by patients with life-threatening medical emergencies and those who ultimately have less serious conditions.
That’s why Reps. Julie Johnson, Tom Oliverson, and Stan Lambert authored HB 1832 and are currently joined by fifteen co-authors. This legislation protects patients from insurance companies’ profit-driven manipulations. Senator Donna Campbell is carrying the companion bill, SB 1282, co-authored by her colleague Sen. Dawn Buckingham.
HB 1832 and SB 1282 will prohibit health plans from implementing any practice that renders coverage for emergency services dependent upon a final diagnosis. Whether or not a symptom, physical complaint, or injury results in a true medical emergency, the ER visit must be covered by insurance. A failure to comply with this regulation will be considered an unfair or deceptive act or practice in the business of insurance.
Passing HB 1832 will be a significant step forward for our state. Rural and major metro area residents alike are rooting for this vital patient protection. Texans’ healthcare rights demand strong protections.
Fortunately, concerned legislators are working to promote good healthcare legislation that will benefit countless lives, and Texas’ freestanding emergency room industry will continue to be on the front lines with them, supporting the vital healthcare needs of Texans across the state.
As originally published on Medium.