Knowing the Difference Between “I’m Not Feeling Well” and “This is a Medical Emergency”

 By Dr. Lon K. Young, MD, FAAEM, Chief Medical Officer 

CapRock Hospital

Every one of us is unique. And while that makes life interesting and adds variety to the world, it represents a challenge for physicians. The individuality of humanity guarantees patients will have widely different symptoms and manifestations of the same disease. And many diseases have overlapping symptoms. Even after more than 20 years in the practice of Emergency Medicine, this variability and overlap proves to be very challenging for me and other ER doctors.

Nevertheless, there are certain symptoms everyone knows do not represent an emergency and should never result in an ER visit, right? Things like a sore throat. Or tooth pain. Or feeling dehydrated. Or shoulder pain. Or “gas” pain. And, since these are never an emergency, our health insurance providers should not be required to cover the costs of ER visits for such complaints, correct?

You probably know where I am going with this. Each of the above, “non-emergent” complaints came from actual patients I have seen and each of these were the only symptom they had indicating they were having a heart attack. Frighteningly, I could make a similar list for symptoms that appeared “non-emergent” but instead represented other life-threatening conditions such as: strokes, pneumonia, meningitis, blood clots in the lungs, arrhythmias, and many others.

Lawmakers nationally and here in Texas have recognized the danger of patients being expected to determine whether or not their medical condition constitutes an emergency. As a result, policymakers enacted federal and state laws that protect the average patient, with these laws long since referred to as the “prudent layperson standard.” This legal standard requires insurers to cover emergency care for patients presenting to a licensed emergency room for the evaluation of:

“…a medical condition of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: 1. placing the person’s health in serious jeopardy; 2. serious impairment to bodily functions; 3. serious dysfunction of a bodily organ or part; 4. serious disfigurement; or 5. in the case of a pregnant woman, serious jeopardy to the health of the fetus.”

Unfortunately, these patient-centered laws are unpopular with insurance companies that profit from finding ways not to pay legitimate claims. As a recent example, Blue Cross/Blue Shield of Texas enacted an “ER patient penalty policy” allowing the denial of payment for ER visits when the visit was for a complaint the insurance company decided in retrospect was not an emergency.

This retroactive policy of denial directly violates not only the spirit of the Prudent Layperson Standard, but more significantly, puts at risk the lives of countless individuals who are now questioning whether or not they should seek ER care in their time of need.

The risk of such policies is obvious. The goal is to scare patients away from the ER unless they are confident they have an actual medical emergency. But, as I have experienced numerous times myself, even an ER doctor cannot identify which tooth pain actually represents a heart attack until after an ER evaluation is conducted. How can we expect patients to know what has taken us many years of advanced medical training to know? The short answer is, we can’t.

To quantify what this could mean to patients, a 2013 study of 140,000 ER visits that examined “non-urgent” presentations to ERs found that:

  • 88 percent received diagnostic testing or treatment;
  • 4 percent were admitted to the hospital; and
  • 5 percent were admitted to the ICU

To make these findings even more concerning, the urgency level of the complaint in this study was determined not by an insurance company, but by a triage nurse.

In this study, most patients required some level of emergent care, but would potentially have payment for such services denied after an insurance company review.

To justify such dangerous policies, insurance companies claim these scare tactics will save large sums of healthcare dollars and reduce premiums. Once you do a little math, you’ll come to realize that is pure nonsense. Unfortunately, there are life-or-death consequences that accompany these flawed insurance company policies.

In the study cited above, nearly 10 percent of the studied ER visits were initially categorized as “non-urgent.” And, overall healthcare spending on ER services has been estimated to be anywhere from 2-10 percent of all healthcare costs. So, even if such policies completely eliminated all non-urgent visits, and even if ER costs were at the uppermost end of estimates, we would save a whopping 1 percent of healthcare costs by denying what health insurance companies see as “excessive” ER visits.

And if you consider only the visits that did not result in any studies or treatment, roughly 2 percent of visits to an ER are actually non-urgent. That means the potential savings on healthcare spending would be only 0.2 percent.

So in order to save between 0.2 and 1 percent of healthcare costs, insurance companies hope to enact policies that will lead to sick patients avoiding the ER or being denied coverage. This irrational, dangerous, and completely anti-patient method of thinking has no place in healthcare. Of all possible healthcare expenses, unplanned emergencies are exactly what insurance should be for.

Ultimately, we can do better—and we will. That’s why ER doctors, nurses, and other members of the emergency care community are fighting hard this legislative session to ensure that Texans medical rights are protected and will be upheld going forward.