All posts tagged health-insurance

LETTER TO THE EDITOR: ER access shouldn’t be dictated by insurers – Columbia Missourian

Anthem Blue Cross/Blue Shield (BCBS), recently notified Missouri plan participants that non-urgent emergency room visits would no longer be covered. This policy is a clear violation of the national prudent layperson standard, which is codified in federal law.

The prudent layperson standard requires insurance coverage be based on a patients symptoms, not their final diagnosis. Anyone seeking emergency care suffering from symptoms that appear to be an emergency should not be denied coverage if the final diagnosis does not turn out to be an emergency.

If you have an Anthem BCBS health insurance plan in Missouri, be aware that nearly 2,000 diagnoses,which Anthem BCBS considers to be non-urgent, would not be covered if you visit the emergency room. Some of these diagnoses are symptoms of medical emergencies. For example:

Anthem BCBS plans to enforce this policy in Missouri this summer.

Missouri participants need to fight for their right to have access to emergency care as protected by the “prudent layperson” standard.

If you are worried that you might have an emergency, you should be able to seek emergency care without wondering if your insurance will cover your ER visit. The vast majority of patients in the emergency department seek care appropriately and often should have come to the ER sooner.

Dr. Jonathan Heidt is president of the Missouri College of Emergency Physicians.

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Letter: Legislators need to go to an emergency room – New Bern Sun Journal

We need a system solution

The fastest way to get some serious reform of the health care system is to have our legislators spend a weekend evening in the local hospital emergency room. I recently had to go to the emergency room in New Bern on a Sunday night and it was an eye opener. Unless you are carried in on a stretcher, you will have to wait hours to see anyone.

New Bern is lucky to have a fully equipped hospital with a caring staff but the emergency room is completely overloaded because regulations require the hospital emergency room to treat anyone who shows up without regard to whether they have insurance or can pay. As a result the ER has become a walk-in clinic for the flu, nose bleeds, sprains, stomach problems, etc., that should be handled by the urgent care clinics. The walk-in clinics want either insurance or payment, so people who dont have insurance go to the ER.

The legislature in Raleigh refuses to expand Medicaid, which could help with this problem. The cutbacks in the public health service, the consolidation of medical practices, and the transforming of ERs into walk-in clinics is a social disaster. One result is hospitals are now charging eye-popping bills for services to cover the losses incurred by their treatment of the uninsured.

Ive even come to realize that single payer or Medicare for all cant work unless we get the costs down. Ive looked at the single payer systems in some of the countries and they all have a robust nonprofit public health system with lower cost health services and more public support for training health professionals.

Its simplistic to say health insurance is for wealth protection or health insurance should be like car insurance. Or the ridiculous comments about people who live the right way dont develop pre-existing conditions. Health insurance is to help control risk so that an unpredictable accident or life threatening illness will not bankrupt most of us. If an accident happens you dont have time to shop around for the cheapest body repair.

We need a system solution that could include: free medical school and health provider tuition so doctors dont come out owing hundreds of thousands of dollars; rebuilding the public health service; more competition in the hospital industry; simpler billing procedures; expanded health insurance for those who cant afford medical services; serious attention to the chemicals in the environment that are leading to diseases.

Unless we look at the American health care system in a systemic way, theres is no chance of tackling this problem.

Sam Love, New Bern

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Blue Cross Blue Shield Wants People in Georgia to Self-Diagnose … – The Intercept

Blue Cross Blue Shield is quietly telling its individual market patientsinGeorgia that it will stop reimbursing some emergency room visits.

The revelation comes fromthe Atlanta Journal-Constitution, which reports that Georgians are getting letters warningthem that the insurer will no longer cover emergency room visits unless it determines them to have been necessary.

This raises the worry from some public health advocates that patients will be afraid to go to the emergency room out of the fear that their treatment will not be reimbursed by their insurer. Laura Harker, a policy analyst who studies Georgias health care system at the Georgia Budget & Policy Institute, explained some of the possible outcomes to The Intercept.

Patients do not always know if they are having a true emergency or not. This policy could make some patients more likely to put off care that they need, Harker said. Many hospitals in rural Georgia are already struggling financially, and this policy could further hurt their bottom line. If BCBS decides that a visit does not count as an emergency, the hospital would most likely not get paid at all. Many patients wouldnt be able to afford the full cost of an ER visit or they could end up with medical debt.

Debbie Diamond, a spokesperson for Blue Cross Blue Shield of Georgia, did not provide a copy of the letters being sent to patients to The Intercept. She did, however, offer a defense of the policy.

Please know that this policy is not intended to keep our members away from the emergency room if that is where they need to be treated. We worked with four board-certified emergency medicine doctors employed by Anthem, our parent company, to develop a list of nonemergency conditions that would be better treated by a patients primary care doctor than in an emergency room, she wrote in an email. The list includes conditions such as suture removals, athletes foot, common cold symptoms and seasonal allergies including itchy eyes.

If a member choses to receive care for these common ailments in the ER when a more appropriate setting is available, their claim will be reviewed by an Anthem medical director using the prudent layperson standard before a determination is made, she continued. In reviewing the claim, the medical director considers the members presenting symptoms that may have appeared to be an emergency even if the diagnosis turned out to be a nonemergency ailment.

TheMedical Association of Georgia, the top lobbying group for physicians in the state, expressed concerns about the shift.

What Blue Cross is asking patients do is determine without a clinical background whether their certain situation is truly an emergency, which is a lot to ask of a patient when theyre obviously presenting themselves to the emergency room because they do have concerns, Executive Director Donald Palmisano told The Intercept.

As the AJC reports, BCBS is the only insurer in the health insurancemarketplace in 96 of Georgias 159 counties. Particularly in rural Georgia, it has a monopoly over patients. As the Washington Postnoted in 2014, southwest Georgia is one of the most expensive places in the nation to buy health insurance.

One way to weakenthat monopoly would befor Georgia to expand Medicaid. Its Republican governor and GOP-dominated legislature have blocked the expansion, and national BCBS funded Republican Governors Association ads attacking unsuccessful Democratic candidate gubernatorial Jason Carter, who campaigned on expanding Medicaid during the 2014 cycle.

By not expanding Medicaid, Georgia puts more of the onus for covering the cost of caring for patients on the hospitals themselves. Hospitals respond by charging people who can pay namely, insurance companies more.

The unnecessary use of emergency departments for ailments that would be better treated at an urgent care center is indeed a real issue, said Palmisano and Harker. But the solution, they said, is better education and preventative and comprehensive care, rather than warning patients their trip to the ER may or may not be covered.

Im happy to say that Im glad that I do not have Blue Cross Blue Shield as my health insurance company withthis kind of restriction, Palmisano said.

Top photo: Patients line the wall of the trauma unit in the emergency room at Grady Hospital in Atlanta on Feb. 18, 2011.

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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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Docs, Dems warn Boston emergency room lines will grow if GOP health bill passes – Boston Herald

Bay State lawmakers and doctors warn that the GOPs health care bill threatens to worsen the emergency room overcrowding crisis, which the Herald reported yesterday has led to wait times in the city that are double the national average.

It is a very serious concern, because that has important health care consequences, but its also a question about resources, said Bay State U.S. Sen. Elizabeth Warren. Thats why I am fighting so hard against the Republican plan to tear up our health care system, because they would actually leave us with fewer health care resources, which means longer waits in all of our hospitals.

According to a Herald special report on emergency rooms, the departments at Boston Medical Center and Brigham and Womens Hospital have wait times of nearly an hour twice as long as the national average.

Massachusetts General Hospital takes two times longer than hospitals nationwide to get ER patients into inpatient treatment.

The American Health Care Act, which cleared the House earlier this month, would scale back the Medicaid coverage that saw a massive expansion under Obamacare.

This has spurred concern that fewer people would have access to primary care physicians, forcing more patients to use emergency services as their only alternative.

The language of the bill could change as it moves through Congress, but the Chief of Emergency Medicine at Massachusetts General Hospital, Dr. David Brown, said as currently written, the health care bill would, among other things, severely cut federal support for Medicaid programs and leave millions without any health insurance at all.

He added, The nations emergency departments, which already serve as a major safety net in health care, will become even more overcrowded than they currently are. This will no doubt impact the quality of care and patient experience.

But Bay State U.S. Rep. Stephen Lynch said Obamacare has caused its own set of problems, one being that hospitals have been forced to operate at full capacity because of the increasing number of Medicaid patients.

Lynch said he plans to reach out to local hospitals to get a sense of what can be done to fix the issue.

Im not surprised its gotten worse, Lynch added, but that doesnt absolve us of the responsibility of fixing the problem, you want to make sure people have access to good doctors and good hospitals in a timely fashion.

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I spent years in the ER with my mom. It isn’t a substitute for real health care. – Shareblue Media

In the last threeyears of my mothers life, she and I spent hour after hour in the emergency room of the hospital. Sitting there, watching great doctors and nurses deal with a stream of patients in various states of crisis, one would quickly realize that the conservative mantra that people without health insurance can simply go to emergency rooms is absolute nonsense.

The wrongheaded idea is not a recent conservative talking point. In 2012, while running against President Obama and in favor of repealing Obamacare, Mitt Romney said, we do provide care for people who dont have insurance, and went on to describe a scenario involving a heart attack and the emergency room.

That isnt a health care system. That is a stop someone from dying system, and as soon as youre stabilized, theyll rush in and ask for your proof of insurance, because the system demands medical professionals also work as collection agents.

My mother suffered from End Stage Renal Diseasein laymans terms, that meant her kidneys were failing. When we rushed her to the emergency room such a frequent occurrence that it has all blurred into one long session with fluorescent lights overhead in my memory, but it was over 20 times between 2012 and 2015 it was because she had tipped over into the danger zone, having trouble breathing or remaining conscious.

The emergency room was helpful. But it wasnt health care. Health care was the multiple visits per week, for hours on end, to the dialysis clinic where the work her kidneys could no longer do was outsourced to a large machine. She had to have the blood in her body removed, processed through the machine, and returned to her.

That is simply not something which can be easily handled by a busy emergency room. Thats an entire system of doctors, nurses, nurses aides, nutritionists, social workers, administrators, and more, working in concert to try to give people some semblance of normalcy as their bodies fail them.

And yes, there are also the families who must deal with this their lives disrupted and forever changed because somebody they love is going through hell. If youve heard the anguished screams of the person who brought you into this world as they suffer in pain, you understand something of what hell is.

And on top of the emotional cost ofthe mental anguish of a severe illness, there is the actual cost to deal with, as well.

My mom was covered. But if she hadnt been, she couldnt just go to the emergency room, and to dismiss serious illness in this way is ghoulish and uncaring and unfeeling to everyone involved.

Yet it has become the go-to for Republicans and conservatives, a sign that they havent really thought about this issue, or that they simply dont care.

Health care real coverage with capable doctors and nurses doing their jobs kept my mom alive so I could sit with her a few more precious hours before she left us. Thats what America needs, not dismissive and insulting slogans from privileged politicians, disconnected from reality.

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I spent years in the ER with my mom. It isn’t a substitute for real health care. – Shareblue Media

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Emergency Room Docs Urging ‘No’ Vote On AHCA – The Daily Caller

As House lawmakers gear up to vote on the American Health Care Act (AHCA) Thursday afternoon, Emergency room physicians are voicing their concerns to members of Congress, urging them to vote no on the Republican plan to repeal and replace Obamacare.

E.R. doctors say the AHCA strips features of Obamacare that secured emergency room services as an essential health benefit. If the AHCA passes, they warn U.S. health care consumers will be left with higher costs for emergency treatment.

The Affordable Care Act included emergency services as an essential health benefit and any replacement legislation must do the same, American College Of Emergency Physicians President Dr. Rebecca Parker said in a statement to The Daily Caller News Foundation.

Dr. Parker argues that any replacement legislation should protect consumers access to emergency care at an affordable price. Patients cant choose where and when they will need emergency care and they shouldnt be punished financially for having emergencies, Dr. Parker said. Federal legislation must ensure that patients having emergencies can seek emergency care knowing their insurer will provide coverage.

Thursdays vote will be the first test for House leadership to see if they have the votes to pass one of President Donald Trumps chief campaign promises, The Wall Street Journal reports. Trump and Speaker Ryan pulled the AHCA just hours before it was slated to go up for a vote in March.

Leadership has spent weeks courting wayward conservative and moderate Republicans behind the repeal effort. House Freedom Caucus Chairman Rep. Mark Meadows and Tuesday Group Leader Rep. Tom MacArthur put forth an amendment in April that is serving as the basis of the new AHCA.

The version would slash many of the Obamacare taxes and subsidies, and cut funding to Medicaid likely to be a point of contention for House Democrats. Another point of debate for Democrats will be that the millions of Americans who obtain health insurance through their employer could be at risk of losing protections that limit out-of-pocket costs for emergency and catastrophic illnesses.

If the AHCA passes the House Thursday, it will move on to the Senate for a vote. As it stands, Senate Republicans remain divided on the AHCA. Republicans hold a slim majority in the Senate with 52 seats, so they cant afford to lose more than 2 votes.

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