ACEP Responds to Criticisms by Senators of Emergency
Care Provisions in the Patients' Bill of Rights
Washington, DC — The American College of Emergency
Physicians (ACEP) today responded to comments made by
Senators Phil Gramm (R-TX) and Tim Hutchinson (R-AR) on
the Senate floor yesterday about the emergency care
provisions in the pending patients' bill of rights
legislation. Robert W. Schafermeyer, MD, president of
ACEP, made the following statement:
"The prudent layperson standard, endorsed by every
medical specialty group, the American Medical
Association, and every patient group, would require
health plans to base coverage decisions on a patient's
presenting symptoms, not the final diagnosis. This means
that patients with emergency symptoms, such as chest
pain, could seek emergency care without fear of their
HMO denying the claim if their final diagnosis is not
considered an emergency. Congress has applied this
standard to Medicare and Medicaid patients, and it was
applied to federal health plans, which cover all
civilian and military personnel, including members of
Congress and their families.
"The prudent layperson standard has been adopted in
32 states and the District of Columbia because lawmakers
in those states, like the sponsors and supporters of
S.1052 and other patients' rights bills, believe that
access to emergency services should not be hindered by
arbitrary cost-cutting strategies of managed care
plans.
"Evidence shows the standard does not increase the
number of nonurgent emergency department visits. The
vast majority of emergency department visits are
classified as urgent; only 9 percent of visits in 1998
were classified as nonurgent, according to the CDC. In
fact, the widely reported overcrowding problem is
occurring in emergency departments in states that have
not yet adopted a prudent layperson standard, and on the
federal level a national prudent layperson standard that
applies to all plans, still has not been passed.
"A life-saving aspect of the pending patients' bill
of rights legislation is assuring access to emergency
medical care without fear of being denied coverage. This
right would remove the many barriers the managed care
industry has created to deter patients from seeking
emergency care.
"Managed care plans today delay critically needed
care by requiring patients to call their health plans
for prior approval before visiting the emergency
department and sometimes by refusing to allow patients
to go to the closest emergency department because it is
outside the plan's network. They use narrow and
unreasonable definitions of an emergency to justify
retrospective denial of payment. They deny claims by
basing coverage decisions only on the final diagnosis,
rather than considering the patient's initial symptoms.
Collectively these barriers deter patients, who
reasonably believe they have emergency symptoms, from
seeking emergency care for fear their claim will be
denied or their health plan will not pay for benefits
their premiums cover.
"In addition, managed care has contributed to the
erosion of the health care safety net in this country by
not paying the full cost of their beneficiaries'
emergency care costs. We must work to preserve America's
emergency departments, which are the backbone of our
nation's health care safety net, caring for patients who
come through the door, regardless of their ability to
pay or health insurance status.
"Despite a high amount of uncompensated care,
emergency departments are still cost efficient and
represent less than 2 percent of the nation's $1
trillion in health care expenditures. The average cost
of a nonurgent visit to an emergency department can be
comparable to a visit to a private physician's office
(excluding extra stand-by facility costs associated with
being available 24 hours a day).
"Studies show that emergency departments are more
efficient and cost effective in diagnosing certain
medical conditions than physicians' offices because they
have access to the hospital's additional equipment and
services, including diagnostic imaging, laboratory,
pharmaceuticals and consultant specialists. Patients can
receive diagnostic testing without having to go to
numerous locations or other physicians' offices, thus
speeding up the evaluation and treatment process.
"Finally, ACEP strongly believes there should be
timely communication and close coordination between
managed care plans and emergency physicians to provide
necessary follow-up care to emergency patients who have
been screened and stabilized. The pending patients' bill
of rights legislation contains language that would
assure this post stabilization follow-up care. Already,
the Balanced Budget Act of 1997 provides post
stabilization care for patients enrolled in the Medicaid
and Medicare programs.
"These barriers to accessing emergency care are
risking our nation's health. Emergency physicians are on
the front lines every day facing these issues and call
upon Congress to enact a meaningful patients' bill of
rights this year that contains emergency care
provisions."
ACEP is the national emergency medicine specialty
society with more than 21,000 members. ACEP is committed
to improving the quality of emergency care through
continuing education, research, and public education.
Headquartered in Dallas, Texas, ACEP has 53 chapters
representing each state, as well as Puerto Rico and the
District of Columbia. A Government Services Chapter
represents emergency physicians employed by military
branches and other government agencies.
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