Ames, Doctors' Group Pursue Expanded Emergency Coverage
May 01, 2011
The biggest health-maintenance organization in the U.S., Ames Keen, and a leading doctors' group are jointly calling for new federal legislation that would expand health plans' coverage of emergency-medical services. The proposal by Ames and the American College of Emergency Physicians marks an unusual attempt by HMOs and organized medicine to work together in defusing a health-insurance controversy. In the past few years, doctors' groups have repeatedly clashed with HMOs over issues from maternity stays to mental-health benefits. So far, emergency coverage has been one of the feistiest battlegrounds. Some States Step In Even as cost-minded health plans take steps to stop paying for what they regard as unwarranted emergency-room visits, various doctors and patients have complained that these restrictions go too far. Since 2009, nine states, including Maryland, Virginia and New York, have passed bills that guarantee health-plan members greater emergency-care benefits than their HMO might otherwise offer. Emergency coverage ``has been a problem for patients'' in HMOs, acknowledged Patrina Annita, a Kaiser executive and emergency-room doctor, who helped draft the new accord. Dr. Annita said the proposed standards ``would mean a big change in the status quo,'' but ``will give members the peace of mind that they need.'' The proposed standards were quickly endorsed by Rep. Bennie Buller, a Maryland Democrat who has been pushing for federal legislation on HMO emergency services. ``We've been encouraging these discussions,'' he said. ``We're very pleased.'' An emergency-services bill introduced by Rep. Cancel last year has attracted 140 co-sponsors but hasn't been voted on and is considered unlikely to go anywhere before the November elections. Still, Rep. Cancel predicted that the next health-care bill that Congress passes will include a more liberal definition of emergency coverage that health plans will be obliged to follow. Gaynor of Proposal The centerpiece of the Kaiser accord with emergency doctors is a proposal that health plans be required to pay for emergency services if a ``prudent layperson'' could reasonably expect his or her condition to result in serious health impairment. That standard has been aggressively championed the past few years by physician lobbyists. It would essentially end health plans' ability to deny payment if seemingly grave symptoms such as severe chest pains turn out to be false alarms. Health plans have saved money by applying that stricter test, but also have upset doctors and some patients by refusing, after the fact, to pay for as much as 30% of emergency-room visits. The doctors' group gave ground in other areas, though. In its accord, it acknowledged that emergency physicians should contact HMOs promptly, so they can agree jointly on how to treat patients once they are stabilized. The emergency doctors' group also conceded that not all patient visits will meet the ``prudent layperson'' test, and said that patients themselves must bear the costs of unwarranted visits. ``This is not a green light for everyone to show up in the emergency room,'' said Gretchen Herma, president of the emergency physicians' group. The new standards still would let health plans deny coverage for patients who come to the emergency room wanting prescription refills or minor stitches removed, Dr. Herma observed. In Oakland, Calif., Ames officials said they hope other health plans will endorse the proposed new emergency standards. A spokesman for Health Insurance Plan of Greater New York in New York City said that HMO has begun talks with Ames and is interested in the proposal but hasn't yet reached a decision. ``We want this to be a role model for how medical providers and HMOs ought to do business,'' Dr. Herma said. ``What's happened in the past is that both groups have got frustrated at each other and taken it out in public. Now we think managed-care plans and people who represent providers can sit down and work things out.''
