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Tough question for hospitals: Who’s too risky to release? – Auburn Citizen

NEW YORK Four days before Alexander Bonds ambushed and killed a New York City police officer, he was in a hospital emergency room getting a psychiatric evaluation. The hospital released him the same day.

Now the hospital’s actions are under a state review ordered by the governor. St. Barnabas Hospital says it handled Bonds appropriately and welcomes the inquiry.

The decision was one psychiatrists across the country make regularly: whether patients pose enough danger to themselves or others to require hospitalization. Practitioners say that it’s often a difficult call to make and that even an experienced evaluator can’t predict someone’s behavior.

“Most of the time, it’s very complicated. You’re trying to make an assessment: Is the person going to a home? Is there family? Are they reliable? What was the specific reason they were brought in? Is that likely to occur again?” said Bea Grause, president of the statewide hospital and health system association HANYS and a former emergency room nurse.

Bonds, 34, evidently had a history of mental health problems. There were antidepressant and anti-psychotic medications in his apartment, and his girlfriend told officers she took him to St. Barnabas for the psychiatric evaluation July 1, police said.

He was observed for seven to eight hours in the emergency room, where he was seen by a physician and then a psychiatrist, hospital spokesman Steven Clark said.

“We believe the proper protocols and standards were met,” he said.

By the night of July 4, Bonds’ paranoid, erratic behavior worried his girlfriend enough that she called police to look for him. They didn’t find him before he marched up to a parked police vehicle and shot through the window just after midnight, striking Officer Miosotis Familia in the head. Soon after, officers shot and killed him after they say he drew a weapon on them.

The state Health Department said it plans to interview St. Barnabas staffers, conduct inspections and examine records to review Bonds’ case and the hospital’s policies and prescribing practices.

Under state law, people can be involuntarily hospitalized for at least 48 hours if they pose a substantial risk of causing serious injury to themselves or others.

“If you’re making a determination that someone’s a danger to themselves or others, you better be pretty clear about it. Because you’re taking away their liberties,” said Grause, whose association represents hospitals and nursing homes.

Psychiatrists caution that the risk can be difficult to pinpoint.

“While psychiatrists can often identify circumstances associated with an increased likelihood of violent behavior, they cannot predict dangerousness with definitive accuracy,” the American Psychiatric Association said in a 2012 position statement.

Doctors and other hospital staffers can encounter agitated emergency room patients they’ve never seen before.

While paying close attention to what patients say and do, doctors also might test to determine whether a medical problem or medication might be spurring the behavior. They consider whether the cause could be alcohol or illegal drugs, a clue sometimes illuminated by observing patients for hours. They may look into whether someone has dementia.

Some patients arrive clearly violent, and others are just having a bad drug reaction that will wear off. But “there’s this vast gray area in the middle that takes a lot of experience, a lot of knowledge and balancing all of the factors that go into a good assessment,” said Dr. Vivian Pender, a New York City psychiatrist and public affairs representative for the New York County Psychiatric Society.

Police have been working to determine Bonds’ motive in shooting Familia. Bonds, who had served prison time for a 2005 armed robbery, had railed about police and prison officers in a Facebook video last September.

Familia, 48, was a 12-year New York Police Department veteran and a mother of three. She was selfless, “incredibly funny” and full of warmth and wisdom, her 20-year-old daughter, Genesis Villella, said Friday.

She “went to work every day proud to do her job, to protect us,” Villella said.

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Georgia Agency To Monitor Blue Cross Emergency Room Policy – WABE 90.1 FM

The state insurance department says it will monitor the new emergency room policy of Blue Cross and Blue Shield of Georgia to make sure that it is not abused to the disadvantage of Georgia policyholders.

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Blue Cross recently told policyholders that starting in July, it will stop covering ER visits it considers to have been unnecessary. The health insurer, Georgias largest, said its pursuing the moveinvolving its coverage of individual policies due to the costs of routine primary care being administered in an ER setting. Physician groups, meanwhile, have been critical of the policy.

Jay Florence, deputy state insurance commissioner, said in a statement that the agency supports insurers attempts to reduce unnecessarily high premiums.

But Florence added, You buy health insurance to make sure you are protected when something bad happens. We are tracking our phone calls and have created a specific code for complaints related to Blue Cross Blue Shields new policy. . . . We will closely monitor this new policy to make sure that it is not abused to the disadvantage of Georgia policyholders.

Routine care is far less expensive than emergency room care, and expertsagree that unnecessary use of ERs is a financial drain on the nations health care system. But what constitutes unnecessary ER use can depend on many factors such as patients symptoms, their perception of their medical condition, their location and other issues.

Blue Cross has cited the high cost of care in formulating its policy.

Were hoping that patients go to the most appropriate setting for care, Blue Cross spokeswoman Debbie Diamond told Georgia Health News. The company has a 24/7 nurse line and online tools that are always available to help members find the right care option for their neighborhood, she added. Urgent care and retail health clinics are other alternatives for patients, Diamond told GHN.

We are not trying to keep people from the ER, she said.

“This policy threatens the safety of all Georgians. There is no way for patients to know which symptoms are life-threatening and which ones are not.” — Dr. Matt Lyon, American College of Emergency Physicians

Blue Cross said its parent company, Anthem, worked with four board-certified emergency medicine doctors to develop a list of non-emergency conditions that would be better treated by a primary care doctor than in an ER. The list includes conditions such as suture removals, athletes foot, common cold symptoms and seasonal allergies including itchy eyes, the insurer said.

The insurer said it would cover ER visits that turn out not to be emergencies if the member was directed to the emergency room by another medical provider, if the services were provided to a child under age 14, if there was no urgent care or retail clinic within 15 miles of the member, or if the visit occurred on a Sunday or a major holiday.

If a member chooses togo to an ER to receive care for the common ailments listed when a more appropriate setting is available, the claim will be reviewed by a Blue Cross medical director using the prudent layperson standard before a determination is made, Blue Cross said.

In reviewing the claim, the medical director will consider whether the member had symptoms that appeared to indicate an emergency even if the diagnosis turned out to be a non-emergency ailment, the insurer added.

Still, the American College of Emergency Physicians (ACEP) said the policy violates the prudent layperson standard, which requires that insurance coverage be based on a patients symptoms, not the final diagnosis.

Anyone who seeks emergency care suffering from apparent emergency symptoms, such as chest pain, cannot be denied coverage even if the final diagnosis does not turn out to be an emergency condition, ACEP said.

This policy threatens the safety of all Georgians, Dr. Matt Lyon, president of GeorgiasACEPchapter, said in a statement. We treat patients every day with identical symptoms some get to go home and some go to surgery. There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.

Lyon added that this action will be especially bad for Georgias rural population, who are often limited in their options for medical care.

Donald Palmisano, executive director of the Medical Association of Georgia, told WABEin May that the Blue Cross policy also might disproportionately affect the elderly, those living in rural areas and adolescents over the age of 14.

I have four children, and if theres an injury and its hard to determine the pain theyre experiencing, its hard to determine whether to go to the emergency room or not, he said.

JeffFusile, president of Blue Cross and Blue Shield of Georgia, told WABE that the cost of cares been going up so much faster than peoples earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.

He also acknowledged, There are lots of gray areas where the diagnosis wasnt so bad after all, but you have to look at the situation the person was in at the time they were in it.

Separately, Blue Cross and Anthem also have to decide whether to remain in the states health insurance exchange. (Heres a recent GHN article on that decision.)

Andy Miller is editor and CEO of Georgia Health News.

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Blue Cross in Georgia to limit emergency room coverage – MyAJC

The Obamacare exchangemay survive next year in rural Georgia. But patients who depend on its last remaining insurer are now learning theres a catch.

Over the past week letters have arrived at homes throughout the state giving patients a jolt. Blue Cross Blue Shield of Georgia, the only insurer on the exchange for 96 of the states 159 counties, is telling patients with individual policies that if they go to the emergency room and its not an emergency, theyll be stuck with the bill.

I am very concerned, said Dr. Matthew Keadey, who leads an organization of ER doctors. He fears patients who need the ER but arent sure they do will avoid it now. If this is fully implemented, I think were going to have deaths out there because of it.

Blue Cross move could stick Keadey and his colleagues with unpaid bills if non-emergency patients continue to come but cant pay. But patients also are concerned.

Really, like what the (heck)? said Sharon Tarver, a patient in Sumter County who has Blue Cross through the exchange, as she described her reaction when she first read the letter.

It was like, OK, well when you think about people that go when they dont have an emergency, they are taking up time for people who have an emergency, that does make sense, Tarver said. But in her area there are only two urgent care clinics, and they close at 8 p.m. and 9 p.m. She recalled two incidents in the past two years when she went to the emergency room, once with chest pain and once with a cough that reminded her of her mothers lung cancer. They both turned out to be something else.

Would she still go now, after the letter?

It depends. Its a half of one hand and half the other, she said.

Trying to change habits

A spokeswoman for Blue Cross said patients with a legitimate fear of an emergency would still be covered and that the company was forced to act by the rising cost of health care.

The policy defines an emergency as what a prudent layperson would think could pose a serious danger, and it says the insurer will decide what makes that cut. It takes effect July 1. Blue Cross says it wont apply to kids 13 and younger, members who dont have an urgent care clinic within 15 miles, or visits on Sundays and major holidays.

This is not to discourage somebody with an emergency condition who needs to go to an ER to go there, said the spokeswoman, Debbie Diamond. Health care is becoming more and more expensive. Its a way to make sure that people are getting quality and affordable care.

Many pressures may have forced the tipping point. Health care prices are always rising, and Obamacare insurance was more expensive to provide at first than companies thought. This year the Trump administration has especially rattled insurance companies by waffling on whether it would continuesubsidies key to funding Obamacare exchange plans.

Blue Cross parent company, Anthem, was reportedly leaning toward pulling out of many states exchange markets. But two weeks ago itsignaled it may stay in Georgias.

And the fact is that patients who use the emergency room like their personal clinic do waste money, a lot of it.

How much is not really known. Keadey quotes data saying a small percentage of ER patients should be getting their care somewhere else.State Rep. Terry England, a co-chairman of a committee that studied how to stabilize rural hospitals, said its much more. But neither disputes that the letter is at least partly aimed at shaking up those people who know they shouldnt be at the ER.

What Im interpreting is its because theyre trying to change habits and get people to focus on going to their physician and not to the ER, England said.

It kind of comes across as cold and callous maybe, the way that theyre doing it, he said. But at the same time, it may be one of the few ways that you actually are able to maintain hospitals andkeep the doors of hospitals openacross the state.

Keadey acknowledged the existence of problem patients. But his larger concern was patients who belong at the ER and may not go.

Patients are not trained to recognize emergencies, he said. What it really is is a barrier to emergency care. Patients will die because theyre going to think twice about going to the emergency department. One person goes and it turns out they just had reflux or a stomach problem; the next person has the symptoms and its a heart attack.

To me its one more way that were seeing the insurance company trying to take their financial responsibility and place it back on the patient.

Sore throat not enough

Diamond said Blue Cross understood patients had to use their best judgment. If you are having chest pains and it turns out to be indigestion, she said, you still thought you were having chest pains. So you could go to the emergency room.

On the other hand, she said, obvious examples where you should not go to the ER would be if you had cold symptoms; if you have a sore throat.

Blue Cross is steering those patients who dont need emergency care to their personal physicians, urgent care clinics or to Blue Cross 24-hour online medical service, LiveHealth Online. The service requires using an app on a computer or on a phone with internet service. It wont work off a rotary phone, for example.

Most people now have cellphones or computers, said Diamond, the Blue Cross spokeswoman.

Not everyone does. Middle-age policymakers might not understand that because a study by the Pew Research Center found that 95 percent to 99 percent of U.S. adults up to age 50 in 2016 used the internet one way or another. But with older people that number falls off a cliff. And with lower-income people and those in rural areas, it can be harder.

We have so many people that come to the library just to have access to a computer and the internet, said Kirk Lyman-Barner, an insurance agent in Sumter County. And thats closed in the evening of course.

Is it an emergency?

In a May 19, 2017, letter to customers, Blue Cross Blue Shield of Georgia said that starting July 1 it would no longer cover non-emergency visits to emergency rooms. This is the definition it gave for emergencies:

Emergency or Emergency Medical Condition means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:

(a) placing the patients health or the health of another person in serious danger or, for a pregnant woman, placing the womans health or the health of her unborn child in serious danger;

(b) serious impairment to bodily functions; or

(c) serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Exceptions to the rule

According to Blue Cross, the rule will not apply if:

GOVERNMENT AND POLITICAL NEWS

If it happens in Washington or under the Gold Dome, The Atlanta Journal-Constitution has somebody there to tell you what it means for all Georgians. Follow our coverage athttp://www.myAJC.com/politics.

You can also join the conversation on Twitter athttp://Twitter.com/GAPoliticsNews or Facebook athttp://facebook.com/gapoliticsnewsnow/.

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Blue Cross Blue Shield To Launch Emergency Room Policy – WABE 90.1 FM

Starting in July, health insurance provider Blue Cross Blue Shield will stop covering emergency room visits it deems unnecessary.

And doctors and analysts have a lot to say about it.

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Blue Cross Blue Shield is enacting this policy because it doesn’t want people to use the emergency room as their primary health care.

“The cost of care’s been going up so much faster than people’s earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system,” says JeffFusile, president of Blue Cross Blue Shield.

Fusile says BCBS wants patients to use urgent care, retail health clinics and their LiveHealth app, which are all cheaper than an ER visit.

“What this policy is directed at is regular, run-of-the mill colds, maybe even influenza. But you don’t need to go to the emergency department to get tested for whether or not you have the flu and to get a Tamiflu prescription,” says JasonHockenberry, who teaches health policy at Emory University.

Hockenberry says, in his research, he’s found many people often use the emergency room inappropriately, for urgent care rather than emergency care.

“This is a real problem. Emergency departments are expensive; they’re there for a different reason. Blue Cross is clearly staking a claim here that we’re going to try to change patient behavior,” Hockenberry says.

Donald Palmisano, president of the Medical Association of Georgia, paints a different picture when it comes to this policy: Imagine a BCBS member has chest pains in the middle of the night. He thinks it might be a heart attack, so he goes to the ER. But it turns out that it was just indigestion. Under BCBS’snew policy, he gets charged for using the emergency room inappropriately. So the next time he has chest pains, he thinks, in case it’s just indigestion, he won’t go to the ER. But this time, it’s a heart attack, and he dies.

“Blue Cross is clearly staking a claim here that we’re going to try to change patient behavior.” – Jason Hockenberry

“That’s where our physicians are concerned. Because they’re like, you know, you’re putting the patient, who doesn’t have the clinical background, to determine whether their condition is of an emergency nature,” Palmisano says.

Palmisano says this policy also might disproportionately affect the elderly, those living in rural areas and adolescents over the age of 14.

“I have four children, and if there’s an injury and it’s hard to determine the pain they’re experiencing, it’s hard to determine whether to go to the emergency room or not. It puts that added stress because you’re dealing with a loved one and you’re putting parents in a very difficult situation,” Palmisano says.

But FusileofBCBS says he knows, in medicine, it’s not always black or white.

“There are lots of gray areas where the diagnosis wasn’t so bad after all, but you have to look at the situation the person was in at the time they were in it,” Fusile says.

Remember that scenario about the man who thinks he’s having a heart attack, but it’s just indigestion? Fusile says that falls into the gray area, too. He says a panel of doctors will assess claims to make sure everyone’s getting fair coverage.

But Palmisano and Hockenberry say they’ll have to wait until the policy is implemented to see how effective it really is.

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Fidget spinner sends child to emergency room – WSAV-TV


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Fidget spinner sends child to emergency room
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Frederick ER reopens after suspicious package investigation – WTOP

WASHINGTON Police are investigating a suspicious package that supposedly burned two adults in Frederick and forced an emergency room to stop admitting patients.

Around noon on Tuesday, two men arrived at Frederick Memorial Hospital complaining of burns and respiratory problems after they opened a package that came in the mail at a home onMilitary Road in Frederick, according to police.

The men brought the package with them to the hospital emergency room, prompting the emergency department to close down to new patients and reroute ambulances to other hospitals, said Lt. Clark Pennington, commander of the investigations division for the Frederick Police Department.

Decontamination tents were set up outside of the emergency room when the package arrived, according to The Associated Press.

The hospital emergency room reopened to new patients around 3 p.m., according to a hospital spokeswoman Melissa Lambdin. She said that the injuries the two men sustained in the incident were not life-threatening.

Operations were back to normal in the hospital on Tuesday afternoon, except for a small area of the emergency department, according toThe Associated Press.

Emergency fire personnel were treating the situation as a hazmat situation. City police and fire officials were investigating to determine the origin of the package, Pennington said.

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