Don’t Deny It

United Healthcare became the most recent insurer to announce a policy of denying payment for what is deemed “unnecessary” emergency department visits.  Within days of its announcement, it said it was delaying the policy change in response to an outcry from healthcare providers and patient advocates. (Anthem put forward a similar policy in 2018, which it subsequently modified substantially under pressure.) While the goal of having the right care in the right place at the right time and at the right cost is reasonable and necessary, the punitive approach being pursued by payers is ill-conceived, unfair, and likely to be counterproductive.

First, let’s be clear about the problem.  I’ve seen no data to suggest that any significant proportion of ED visits are unnecessary in the sense that the patient didn’t actually need medical attention.  Rather, a substantial fraction of visits to the ED (estimates range from around 20% to over 60%) are for problems that could be managed in a different setting (e.g., primary care, urgent care). Because charges for ED visits are typically far higher than for those other settings (I say charges because there is some disagreement about whether the cost of such visits is actually higher, but that’s a blog for another time…), having that care provided in a different setting when appropriate could decrease health care spending while maintaining the effectiveness of the care and perhaps improving the experience.

So why do people go the ED when they could go someplace else?  Policies based on a financial disincentive seem to be predicated on the idea that people are intentionally misusing the system: I know I could go someplace else but my insurance is paying for it so what the heck.  But research has shown that ED visits for non-urgent problems are correlated largely with lack of accessible, quality alternatives; lower levels of health literacy; or a true belief that something is or at least might be an emergency. (Chest pain is an emergency whether it ends up being a heart attack or indigestion.)  In all my years of practicing emergency medicine, I encountered far more people being gamed by the system than those trying to game it.

Which is why such policies are ill-conceived – they don’t address the root cause which is lack of real access to lower-priced options.  They are also unfair.  Unfair to providers because emergency departments are legally and morally obligated to treat all who come to them.  Threatening not to pay them for the services they provide puts them at risk.  Unfair to patients because non-payment may prevent those without alternatives from getting care they need.  And barriers to accessing other sites of care are more prevalent among those with public insurance and those in higher poverty neighborhoods and those with more people of color. Denial of payment becomes one more source of inequity.

What’s worse, such policies are unlikely to achieve their goal of reducing spending, and may even increase it.  To start with, the vast majority of denied claims end up getting paid.  For example, in 2020 when Aetna was sued for inappropriate denial of emergency claims in California, the court found that 93% of the denied claims should have been allowed according to Aetna’s criteria.  However, the process requires the provider to appeal, generating a ton of paperwork and additional expense.  Second, the process for validating the “appropriateness” of the claim is likely to drive unnecessary utilization.  Approval of the claim is based in part on “the intensity of diagnostic services performed” and treatments provided (for example, visits in which IV medications or fluids are given are automatically approved).  We know that a good deal of diagnostic testing is unnecessary; this policy would incentivize additional testing as a way to justify the visit.  It would also incentivize therapeutic escalation – for instance, IV fluids instead of the equally effective oral rehydration.  All of this would actually add to the cost of care.

Excessive spending for care in emergency departments that could reasonably and safely be provided elsewhere is a problem.  Better and more equitable access to less expensive alternatives (effective triage lines, expanded primary care and urgent care hours, virtual care) would be a better approach than punishing patients and providers by denying payment.

One Response to Don’t Deny It

  1. Chris Lutze says:

    You should run for governor Mark! How timely your story! After considerable time and energy today to get my homebound mom seen for a systemic rash, she’s had for 2 wks. I was told by clinic staff if I wanted her eval. earlier than end of July I could call an ambulance to take her to the ER. Being a nurse, I thought wow for a rash? I guess Ill be taking her by car to urgent care. I think a shortage of physicians and nurses is also a growing concern! Thanks for your advocacy!

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