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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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