"Health insurance companies, and especially this one, have historically used these types of tools as a way to justify denying legitimate medical claims and padding their profits," said Jay Kaplan, MD, FACEP. "It is very alarming that a report like this is being issued because it undermines the language in the ACA and patients' responsible use of the emergency department."
The report assesses whether emergency visits for certain conditions could have been avoided, based on the patients' final diagnoses, not their presenting symptoms. The data does not take into consideration the national "prudent layperson" standard, which says emergency visits must be covered by insurance companies based on the patients' symptoms, not their final diagnoses. This standard was included in the Patient Protection and Affordable Care Act (ACA). It also directly contradicts data from the Centers for Disease Control and Prevention which says that the vast majority (96 percent) of emergency patients seek care appropriately. http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf
Dr. Kaplan adds that patients never should be forced into the position of self-diagnosing their medical conditions out of fear of insurance not covering the visit. For example, this report cites sprains and strains as a "potentially preventable" condition in the ER. But does a patient have a severe strain or a broken leg? Another condition cites is abdominal pain. This can be the symptom of something life-threatening, like a heart attack, an abdominal aortic aneurysm or an ectopic pregnancy, not just indigestion. It's not always possible for a patient to know unless he or she gets a medical examination. In addition, some patients, with certain conditions make the mistake of delaying seeking medical care when they are truly having an emergency.
"A report like this may discourage some people from visiting the emergency department who really should be there," said Dr. Kaplan. "The consequences of that could be (and has been) tragic."
Many people still do not have access to patient-centered medical homes and as a consequence, turn to the emergency department for care. While we certainly support everyone having access to a primary care physician, that's not always an option if they need a timely appointment.
"I treat patients in the emergency department daily who couldn't access a primary care physician," said Louise A. Prince, MD, FACEP, president of ACEP's New York State Chapter. "They had no choice but to come to the emergency department for treatment."
Four in five people who contacted their primary care physician or other medical provider before seeking emergency care were told to bypass their doctor's office and go directly to the emergency room, according to a 2013 report by the RAND Corporation.
Many patients are also redirected from urgent care centers. Nearly three-quarters (71 percent) of emergency physicians responding to a poll in 2015 said they treated patients every day who ended up in the ER after first seeking help in an urgent care that was not equipped to care for them. More than half (54 percent) of emergency physicians say urgent care centers are marketing themselves as alternatives to the emergency department.
According to a report from the Center for Studying Health System Change (HSC), many assessments of "unnecessary" use of emergency care incorrectly look at patients' diagnoses, instead of patients' symptoms and why they are choosing to seek emergency care. A study conducted by HSC in 2012 found that most emergency visits by Medicaid patients were for urgent or more serious symptoms. A study published in the Journal of the American Medical Association (JAMA) in 2013 found that most patients with so-called "primary care treatable" diagnoses come to the emergency department with identical symptoms to patients with true emergencies.
ACEP is a national medical specialty society representing emergency medicine. ACEP is committed to advancing 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.