Patients bypassing primary doctors for emergency care

With the growth of "prudent layperson" laws and other pressures, health plans are backing off from strict limits on visits to the emergency department.

By Leigh Page, AMNews staff. Feb. 12, 2001.

Now that managed care's finger is out of the dike, patients are flooding into the emergency department.

Aetna U.S. Healthcare, Cigna Healthcare and Humana report double-digit increases in ED use in markets such as Dallas and Cincinnati. UnitedHealthcare reports a 20% boost nationwide in the past two years.

Plans blame the increased ED volume on "prudent layperson" laws passed in 33 states, which require them to pay ED bills if the patient is in great pain or believes he or she is in a medical emergency. Also cited are plans' abandonment of prior authorization requirements for emergency care and patients' shift to PPOs, which usually do not require selection of a primary care physician who must grant a referral to the ED.

Some say patients are using the ED because they are having a more difficult time getting in to see their primary care doctor. So plans such as Aetna reward some doctors for evening and weekend hours as one piece of a bonus payment distributed as a lump sum at the end of the year. And Humana said that, during some contract negotiations, it encourages practices to commit to same-day scheduling.

Douglas Hancher, MD, says his four-member family practice in Springdale, Ohio, near Cincinnati, is open four evenings and for a few hours on Saturdays. At those times "we're always very full. We have a lot of patients who want to come in when they are done with work."

He said plans do not pay him extra for the special hours, but they do send him profiles of his patients' ED visits use and "ultimately, I guess they could remove you from their panel if you closed shop at 4:30 and told everyone to go to the ER." [...]