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Thompson RC, Al-Mallah MH, Beanlands RSB, Calnon DA, Dorbala S, Phillips LM, Polk DM, Soman P. ASNC's thoughts on the AHA/ACC chest pain guidelines. J Nucl Cardiol 2022; 29:19-23. [PMID: 34782993 DOI: 10.1007/s12350-021-02856-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Randall C Thompson
- St. Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA.
| | | | - Rob S B Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | | | | | - Prem Soman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Thompson RC, Bateman TM, Blankstein R, Di Carli MF, Heydari B, Hung J, Kwong RY, Lindner JR, Nieman K, Dorbala S. A Policy Statement on Cardiovascular Test Substitution and Authorization: Principles of Patient-Centered Noninvasive Testing. J Am Coll Cardiol 2021; 78:1385-1389. [PMID: 34556324 DOI: 10.1016/j.jacc.2021.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Timothy M Bateman
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ron Blankstein
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bobak Heydari
- Stephenson Cardiac Imaging Center, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA; Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Koen Nieman
- Stanford University School of Medicine and Cardiovascular Institute, Stanford, California, USA
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Chou SC, Gondi S, Baker O, Venkatesh AK, Schuur JD. Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses. JAMA Netw Open 2018; 1:e183731. [PMID: 30646254 PMCID: PMC6324426 DOI: 10.1001/jamanetworkopen.2018.3731] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Insurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent. OBJECTIVE To characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits. MAIN OUTCOMES AND MEASURES Each visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined. RESULTS From 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred. CONCLUSIONS AND RELEVANCE Anthem's nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Suhas Gondi
- Harvard Medical School, Boston, Massachusetts
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan. J Gen Intern Med 2018; 33:722-728. [PMID: 29352418 PMCID: PMC5910334 DOI: 10.1007/s11606-017-4245-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/22/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. OBJECTIVE To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. DESIGN AND METHODS This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. KEY RESULTS Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. CONCLUSIONS We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.
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Appropriations for "appropriate" visits: Payment denials for emergency department care. Am J Emerg Med 2017; 36:1511-1512. [PMID: 29305024 DOI: 10.1016/j.ajem.2017.12.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/27/2017] [Indexed: 11/23/2022] Open
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Affiliation(s)
- Kevin R Riggs
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street Room 2-604B, Baltimore, MD, 21287, USA,
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Pukurdpol P, Wiler JL, Hsia RY, Ginde AA. Association of Medicare and Medicaid insurance with increasing primary care-treatable emergency department visits in the United States. Acad Emerg Med 2014; 21:1135-42. [PMID: 25308137 PMCID: PMC7255778 DOI: 10.1111/acem.12490] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Policymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits. METHODS This was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression. RESULTS Compared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals. CONCLUSIONS These findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.
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Affiliation(s)
- Paul Pukurdpol
- The Departments of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Patterson PD, Lave JR, Martin-Gill C, Weaver MD, Wadas RJ, Arnold RM, Roth RN, Mosesso VN, Guyette FX, Rittenberger JC, Yealy DM. Measuring adverse events in helicopter emergency medical services: establishing content validity. PREHOSP EMERG CARE 2013; 18:35-45. [PMID: 24003951 DOI: 10.3109/10903127.2013.818179] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). METHODS We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the framework's content. RESULTS The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. CONCLUSIONS We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.
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Affiliation(s)
- P Daniel Patterson
- From the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Raven M, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits. JAMA 2013; 309:1145-53. [PMID: 23512061 PMCID: PMC3711676 DOI: 10.1001/jama.2013.1948] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care. OBJECTIVE To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use. DESIGN, SETTING, AND PARTICIPANTS The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses. MAIN OUTCOMES AND MEASURES Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits. RESULTS Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room. CONCLUSIONS AND RELEVANCE Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.
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Affiliation(s)
- Maria Raven
- Department of Emergency Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94707, /917-499-5608 (mobile)
| | - Robert A. Lowe
- Department of Medical Informatics and Clinical Epidemiology, Department of Emergency Medicine, Department of Public Health and Preventive Medicine, Senior Scholar, Center for Policy and Research in Emergency Medicine (CPR-EM), Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC-504, Portland, Oregon 97239-3098, /503 494-7134
| | - Judith Maselli
- Department of Medicine, University of California, San Francisco, 3333 California St, Box 1211, San Francisco, CA 94143-1211, / 415-502-4068
| | - Renee Y. Hsia
- University of California San Francisco, San Francisco General Hospital, Department of Emergency Medicine, 1001 Potrero Ave, 1E21, San Francisco, CA 94110, / 415-206-4612
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Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiró S, Argimon JM. Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review. PLoS One 2012; 7:e35903. [PMID: 22567118 PMCID: PMC3342316 DOI: 10.1371/journal.pone.0035903] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 03/23/2012] [Indexed: 11/18/2022] Open
Abstract
Background Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization. Methodology/Principal Findings We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost). Conclusions/Significance The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253
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Affiliation(s)
- Gemma Flores-Mateo
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol, Barcelona, Spain.
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Durand AC, Gentile S, Gerbeaux P, Alazia M, Kiegel P, Luigi S, Lindenmeyer E, Olivier P, Hidoux MA, Sambuc R. Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France. BMC Emerg Med 2011; 11:19. [PMID: 22040017 PMCID: PMC3215166 DOI: 10.1186/1471-227x-11-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 10/31/2011] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED. METHODS We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit. RESULTS Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%). CONCLUSIONS The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.
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Affiliation(s)
- Anne-Claire Durand
- Laboratoire de Santé Publique, Faculté de Médecine, Equipe de recherche EA 3279 "Evaluation hospitalière-Mesure de la santé perçue", Marseille, France
| | - Stéphanie Gentile
- Laboratoire de Santé Publique, Faculté de Médecine, Equipe de recherche EA 3279 "Evaluation hospitalière-Mesure de la santé perçue", Marseille, France
| | - Patrick Gerbeaux
- Service d'Accueil des Urgences, Hôpital de La Conception, Marseille, France
| | - Marc Alazia
- Service d'Accueil des Urgences, Hôpital Sainte Marguerite, Marseille, France
| | - Pierre Kiegel
- Service d'Accueil des Urgences, Hôpital du Pays d'Aix, Aix en Provence, France
| | - Stephane Luigi
- Service d'Accueil des Urgences, Centre Hospitalier Général, Martigues, France
| | - Eric Lindenmeyer
- Service d'Accueil des Urgences, Hôpital Saint Joseph, Marseille, France
| | - Philippe Olivier
- Service d'Accueil des Urgences, Hôpital Henri Duffaut, Avignon, France
| | | | - Roland Sambuc
- Laboratoire de Santé Publique, Faculté de Médecine, Equipe de recherche EA 3279 "Evaluation hospitalière-Mesure de la santé perçue", Marseille, France
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Lowe RA, Schull M. On easy solutions. Ann Emerg Med 2011; 58:235-8. [PMID: 21546118 DOI: 10.1016/j.annemergmed.2011.03.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 03/25/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
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Simonet D. Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability. HEALTH CARE ANALYSIS 2008; 17:1-19. [PMID: 18306043 DOI: 10.1007/s10728-008-0081-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 01/14/2008] [Indexed: 10/22/2022]
Abstract
Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999-2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to "stabilize" a patient suffering from an "emergency medical condition" before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users' characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.
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Affiliation(s)
- Daniel Simonet
- Nanyang Technological University (NTU), Nanyang Business School, Singapore 639798, Singapore.
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Preauthorization of CT and MRI examinations: assessment of a managed care preauthorization program based on the ACR Appropriateness Criteria and the Royal College of Radiology guidelines. J Am Coll Radiol 2007; 3:851-9. [PMID: 17412184 DOI: 10.1016/j.jacr.2006.04.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate computed tomography (CT) and magnetic resonance imaging (MRI) utilization patterns before and after the implementation of a preauthorization program based on the ACR Appropriateness Criteria((R)) and the guidelines of the Royal College of Radiologists. MATERIALS AND METHODS All CT and MRI requests received at the preauthorization center and CT and MRI examinations actually performed were identified by our health care service's centralized computerized database between January 1, 2000, and December 31, 2003. The obligatory preauthorization of CT and MRI requests was established for CT in September 2001 and for MRI in February 2002. All ambulatory CT and MRI examination requests sent for approval during the study period by most of our health care physicians were included in the study. The preauthorization program model is presented, and multiple parameters were evaluated from January 2000 to December 2003, before and after preauthorization was established. RESULTS Before preauthorization was required, the CT and MRI utilization rates were constantly increasing by 20% and 5% per year for CT and MRI, respectively. After preauthorization was implemented, CT and MRI annual performance rates decreased from 25.9 and 7 examinations per 1,000, respectively, in 2000 to 17.3 and 5.6 examinations per 1,000, respectively, in 2003. The decreases in the utilization of MRI and CT imaging between 2001 and 2003 were 9% (12,129 compared with 11,070 MRI examinations) and 33% (81,223 compared with 57,204 CT examinations), respectively, resulting in substantial, statistically significant cost savings. The deferral rate ranged from 7.5% to 12.2% (mean = 9.8%) for CT and 13.9% to 21.4% (mean = 17%) for MRI. Deferred cases in CT were most commonly in neuroradiology, musculoskeletal radiology, and CT angiography (ranges of deferred cases 9% to 12%, 11% to 12%, and 10% to 12%, respectively). Deferred cases in MRI were most commonly in abdominal and chest radiology (ranges of deferred cases 32% to 37% and 20% to 31%, respectively). Computed tomography was more commonly utilized inappropriately by pediatric professions, and MRI was more commonly utilized inappropriately by medical subspecialty professions. CONCLUSION Preauthorization of CT and MRI requests results in a substantial decrease in utilization of these modalities with reduction in imaging costs.
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Abstract
This chapter addresses past successes and challenges and then elaborates on the potential for further advances in three areas that bridge emergency medicine and the broader public health and health services research agenda: (1) monitoring health care access; (2) surveillance of diseases, injuries, and health risks; and (3) delivering clinical preventive services. This article also suggests ways to advance policy-relevant research on systems of health and social welfare that impact the health of the public.
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Affiliation(s)
- Karin V Rhodes
- Department of Emergency Medicine, School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Bamezai A, Melnick G, Nawathe A. The cost of an emergency department visit and its relationship to emergency department volume. Ann Emerg Med 2005; 45:483-90. [PMID: 15855942 DOI: 10.1016/j.annemergmed.2004.08.029] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE This article addresses 2 questions: (1) to what extent do emergency departments (EDs) exhibit economies of scale; and (2) to what extent do publicly available accounting data understate the marginal cost of an outpatient ED visit? Understanding the appropriate role for EDs in the overall health care system is crucially dependent on answers to these questions. The literature on these issues is sparse and somewhat dated and fails to differentiate between trauma and nontrauma hospitals. We believe a careful review of these questions is necessary because several changes (greater managed care penetration, increased price competition, cost of compliance with Emergency Medical Treatment and Active Labor Act regulations, and so on) may have significantly altered ED economics in recent years. METHODS We use a 2-pronged approach, 1 based on descriptive analyses of publicly available accounting data and 1 based on statistical cost models estimated from a 9-year panel of hospital data, to address the above-mentioned questions. RESULTS Neither the descriptive analyses nor the statistical models support the existence of significant scale economies. Furthermore, the marginal cost of outpatient ED visits, even without the emergency physician component, appear quite high--in 1998 dollars, US295 dollars and US412 dollars for nontrauma and trauma EDs, respectively. These statistical estimates exceed the accounting estimates of per-visit costs by a factor of roughly 2. CONCLUSION Our findings suggest that the marginal cost of an outpatient ED visit is higher than is generally believed. Hospitals thus need to carefully review how EDs fit within their overall operations and cost structure and may need to pay special attention to policies and procedures that guide the delivery of nonurgent care through the ED.
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Lowe RA, Localio AR, Schwarz DF, Williams S, Tuton LW, Maroney S, Nicklin D, Goldfarb N, Vojta DD, Feldman HI. Association between primary care practice characteristics and emergency department use in a medicaid managed care organization. Med Care 2005; 43:792-800. [PMID: 16034293 DOI: 10.1097/01.mlr.0000170413.60054.54] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes. OBJECTIVES We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices. RESEARCH DESIGN This was a cohort study. SUBJECTS A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included. MEASURES Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics. RESULTS On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants. DISCUSSION Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use. CONCLUSIONS Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.
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Affiliation(s)
- Robert A Lowe
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Shields AE, Comstock C, Finkelstein JA, Weiss KB. Comparing asthma care provided to Medicaid-enrolled children in a Primary Care Case Manager plan and a staff model HMO. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2003; 3:253-62. [PMID: 12974661 DOI: 10.1367/1539-4409(2003)003<0253:cacptm>2.0.co;2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine differences in selected processes of asthma care provided to Medicaid-enrolled children in a state-administered Primary Care Case Manager (PCCM) plan and a staff model health maintenance organization (HMO). METHODS Retrospective cohort study assessing performance on 6 claims-based processes of care measures that reflect aspects of pediatric asthma care recommended in national guidelines. Analyzed Medicaid and HMO claims and encounter data for 2365 children with asthma in the Massachusetts Medicaid program in 1994. RESULTS There were no plan differences in asthma primary care visits, asthma pharmacotherapy or follow-up care after asthma hospitalization. Children in the HMO were only 54% as likely (confidence interval [CI]: 0.37-0.80; P<.01) as those in the PCCM plan to experience an asthma emergency department (ED) visit or hospitalization. HMO-enrolled children were only half as likely (CI: 0.38-0.64; P<.001) to meet the National Committee for Quality Assurance (NCQA) definition for persistent asthma and only 32% as likely (CI: 0.19-0.56; P<.001) to have prior asthma ED visits or hospitalizations relative to children in the PCCM plan. Controlling for case mix and other covariates, children in the HMO were 2.9 times as likely (CI: 1.09-7.78; P<.05) as children in the PCCM plan to receive timely follow-up care (within 5 days) after an asthma ED visit and 1.8 times as likely (CI: 1.05-3.01; P<.05) as those in the PCCM plan to receive a specialist visit during the year. CONCLUSIONS In this study, the HMO served a less sick pediatric asthma population. After controlling for case mix, the staff model HMO provided greater access to asthma specialists and more timely follow-up care after asthma ED visits relative to providers in the state-administered PCCM plan. Further understanding of the impact of these differences on clinical outcomes could guide asthma improvement efforts.
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Abstract
In the last 5 years, the understanding of the epidemiology and pathogenesis of pediatric sepsis, septic shock, and multiple organ failure has expanded greatly. There has also been a substantial increase in the number of successful randomized trials in which success has been measured as reduction in mortality in adults, children, and newborns. This article discusses these advances, updating the 1997 article on septic shock written by the author and by Dr. Robert E. Cunnion and following the format of the 1997 article.
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Affiliation(s)
- Joseph A Carcillo
- Division of Critical Care Medicine, Children's Hospital of Pittsburgh, 3705 5th Avenue, Pittsburgh, PA 15123, USA.
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Pollock DA, Lowery DW, O'brien PM. Emergency medicine and public health: new steps in old directions. Ann Emerg Med 2001; 38:675-83. [PMID: 11719749 DOI: 10.1067/mem.2001.119457] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emergency medicine and public health have opportunities to interact in at least 4 areas: surveillance of diseases, injuries, and health risks; monitoring health care access; delivering clinical preventive services; and developing policies to protect and improve the public's health. Recent, cross-cutting initiatives and innovations in these 4 areas follow pathways first explored more than a generation ago and provide an important impetus for future work. An analysis of recent contributions also points to various obstacles and challenges that must be addressed to take full advantage of existing and rapidly developing ties between emergency medicine and public health. The connections between these 2 fields will continue to create important partnership opportunities and the strong possibility of achieving new benefits for patients, the public, and the professionals who serve them.
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Affiliation(s)
- D A Pollock
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA.
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Lowe RA, Chhaya S, Nasci K, Gavin LJ, Shaw K, Zwanger ML, Zeccardi JA, Dalsey WC, Abbuhl SB, Feldman H, Berlin JA. Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers. Acad Emerg Med 2001; 8:259-66. [PMID: 11229948 DOI: 10.1111/j.1553-2712.2001.tb01302.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. METHODS A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. RESULTS African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). CONCLUSIONS African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.
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Affiliation(s)
- R A Lowe
- Department of Biostatistics and Epidemiology, University of Pennsylvania Medical Center, and Philadelphia Emergency Medicine Research Consortium, Philadelphia, PA, USA.
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Shesser R, Holtermann K, Smith J, Braun J. Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process. Ann Emerg Med 2000; 36:212-8. [PMID: 10969222 DOI: 10.1067/mem.2000.109167] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVES We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. METHODS All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. RESULTS We reviewed 1,830 records; 836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P <.001). Excluding the 529 suspended claims, McNemar's statistical testing of 1,302 records failed to demonstrate the equivalence of the 2 systems (P <. 001). CONCLUSION Compared with the standard ED claims review process used by the managed care industry, provider self-adjudication using a symptom-based system approves a greater proportion of visits, avoids rejection of many ED visits, and identifies many nonemergency visits that mistakenly appear to be emergencies. The possibility of providers and MCOs working together to adjudicate outpatient ED claims should be explored.
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Affiliation(s)
- R Shesser
- Department of Emergency Medicine, George Washington University, Washington, DC.
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Wenner WJ. Managed care: a problem or a solution in the health care of children. CURRENT PROBLEMS IN PEDIATRICS 2000; 30:213-22. [PMID: 11002836 DOI: 10.1067/mps.2000.109066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- W J Wenner
- Children's Hospital of Philadelphia, Pennsylvania, USA
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Neely KW. Managed care and EMS: an interrogatory model to assist communities in evaluating innovative partnerships. National Association of EMS Physicians Managed Care Task Force. PREHOSP EMERG CARE 2000; 4:274-9. [PMID: 10895925 DOI: 10.1080/10903120090941335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- K W Neely
- Department of Emergency Medicine, Oregon Health Sciences University, Portland 97291-3098, USA.
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Derlet RW. Locked Gates: Profit and Pain. Acad Emerg Med 2000. [DOI: 10.1111/j.1553-2712.2000.tb03835.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Seaberg DC, Stimler JE, Wears RL. Effect of state legislation prohibiting denial of emergency department patient claims. Ann Emerg Med 2000; 35:267-71. [PMID: 10692194 DOI: 10.1016/s0196-0644(00)70078-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE On July 1, 1996, two Florida state laws were implemented to prevent denial of legitimate patient claims. Our objective was to determine whether the laws have been effective in reducing inappropriate denials as measured by the proportion of claims and charges denied. METHODS A comprehensive set of claims for in-state emergency physician services from a physician billing company were analyzed for the period January 1996 through June 1997, covering 6 months before and 12 months after the effective date of state legislation. The number of facilities included in the data varied from 55 to 67 (mean 63). Denials were classified into 6 categories by payer type. Gross denials were those claims that were completely not paid by the payer, net denials represented the amount denied after patient payments. Downcoding was not examined in this study. Main outcome measures were the proportion of claims and charges denied before and after July 1, 1996. RESULTS The classification of relative proportions of primary payers did not change appreciably over the study period. The proportion of denied claims decreased significantly (Kruskal-Wallis P <.001), starting 2 months after implementation. CONCLUSION After initiation of state legislation, payers continue to inappropriately deny claims, although the number of claims and total charges denied has decreased. In response to this legislation, payers are denying larger claims and patient copayments have increased.
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Affiliation(s)
- D C Seaberg
- Department of Emergency Medicine, University of Florida Health Science Center, Jacksonville, FL 32209, USA.
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Abstract
The growth of managed care has provided health benefits to millions of children while attempting to control the increase in health care costs. In adhering to these goals, MCOs are often at odds with emergency departments, and the emergency department physicians providing emergency care. The appropriateness or inappropriateness of emergency department visits can be disputed, but no criteria have been established. Even the definition of emergency is debated, although many states are adopting a prudent layperson standard. Emergency medicine physicians, primary care providers, and MCOs must cooperate to fully educate parents about the appropriate use of pediatric emergency services. Patients and MCOs should use facilities that can deliver pediatric emergency and critical care or provide appropriate transport systems to facilities that can. COBRA and EMTALA set the legal requirements to which emergency departments must comply when patients present for care. The basic caveats under COBRA require a medical screening examination for every patient and the stabilization of all patients with emergency medical conditions before inquiring about insurance or patients' ability to pay. A part of gatekeeping, MCOs often require authorization for treatment. MCOs authorize payment only. Evaluation and emergency treatment should not be withheld pending authorization. After the medical screening examination, recommended treatment should be in patients' best interests. All patients with potentially life-threatening conditions should be stabilized before transport, and all transfers must comply with the EMTALA. The transfer of unstable patients purely for economic reasons is a violation of the EMTALA. When stable, patients may be transferred to other facilities, but patients requiring specialty care should be taken to facilities best able to provide that care. Financial considerations should be superseded by medical necessity. Finally, improvements can be made in the way emergency medical service is provided to children within the current managed care system. The primary care provider is in a key position to inform parents about the types of pediatric emergencies, what to do in case one occurs, and to provide follow-up care. MCOs should incorporate clear information on pediatric emergencies. A mutual understanding of services needed, and how best to provide those services, are needed to forge a system that is responsive to children's emergency care needs.
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Affiliation(s)
- D Hodge
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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Dickinson ET, Verdile VP, Duncan T, Bryant KA. Managed care enrollee utilization of 911 medical services. PREHOSP EMERG CARE 1999; 3:321-4. [PMID: 10534033 DOI: 10.1080/10903129908958962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the mechanism by which managed care organization (MCO) enrollees enter the emergency medical services (EMS) system. METHODS All enrollees belonging to the region's largest MCO and transported to emergency departments by a paramedic-level municipal EMS system were identified from billing records. Dispatch logs were examined to determine the time and origin of the call to the 911 communication center. Patient care records were used to obtain age, the level of care delivered (advanced or basic life support), and whether the patient received any medications while out of hospital. Hospital admission was also determined. RESULTS Over a six-month period, 195 enrollees were transported. Three modes of 911 EMS system entry were identified: group I-enrollees who called 911 directly; group II-enrollees who called the MCO triage center, who then called 911 on behalf of the patient; and group III--enrollees who were sent to the MCO health center for evaluation, and subsequently the MCO called 911 to transfer the patient to the hospital. Of the 195 patients transported to the emergency department, the dispositions of 108 (55%) patients were obtained. Group I (n = 109) patients were more likely to be transported in the evening (3 PM to 11 PM), less likely to require advanced life support therapies, and less likely to be admitted to the hospital when compared with groups II (n = 32) and III (n = 54) patients. Group III patients were the most likely to receive advanced life support care and require admission to the hospital. CONCLUSION The majority of MCO enrollees called 911 directly, and were most likely to do so during evening hours. Enrollees who called 911 directly (group I) had a trend toward lower acuity, based on the lowest ALS utilization of any group. Those enrollees who most frequently required advanced life support were those who received initial treatment at the MCO center prior to EMS transport. Though EMS system-specific, this type of descriptive analysis is helpful in assisting both EMS systems and MCOs to better assess utilization of 911 EMS resources by MCO enrollees. This study also challenges the prudent layperson paradigm.
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Affiliation(s)
- E T Dickinson
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia 19140, USA
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Neely KW, Norton RL. Survey of health maintenance organization instructions to members concerning emergency department and 911 use. Ann Emerg Med 1999; 34:19-24. [PMID: 10381990 DOI: 10.1016/s0196-0644(99)70267-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Anecdotal concerns suggest that health management organization (HMO) membership instructions may deter members from calling 911 or going to an emergency department for a perceived emergency. This study examines such instructions, specifically in regard to their definition of an emergency condition and associated instructions. METHODS Member instructions were requested from 28 HMOs in 3 large West Coast cities with HMO penetration exceeding 30%. Fifteen (54%) provided membership materials. Features examined included the definition of an emergency, instructions for calling 911, specific instructions regarding chest pain and stroke, and mention of costs associated with emergency care. RESULTS Instructions and definitions varied widely. Six HMOs (40%) included chest pain in their definition of an emergency; 2 (13%) included symptoms of stroke. Ten (67%) made mention of calling 911 or going to the ED somewhere within their instructions; 4 (27%) provided no options for calling 911 or seeking ED care. Three (20%) cited higher costs associated with ED care. Eleven (73%) indicated that claims would be denied for visits determined on retrospective review to be nonemergencies. CONCLUSION Instructions varied considerably. Most did not include chest pain or symptoms of stroke in their definition of an emergency. Most did include directions to call 911 or go to an ED. Other instructions may lead members to call the HMO first during an emergency.
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Affiliation(s)
- K W Neely
- Department of Emergency Medicine, Oregon Health Sciences University, Portland, OR, USA.
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Delay in Gynecologic Surgical Treatment. Obstet Gynecol 1999. [DOI: 10.1097/00006250-199906000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
To determine the public's perception as to the general definition of an emergency medical condition (EMC), and to compare opinions between the general public and healthcare workers (HCW) on which specific medical conditions require emergency department (ED) care, a survey of people at 12 supermarkets and shopping malls in Northern California was conducted over a 6-month period in 1997. Individuals over age 18 were asked in person to complete a survey sheet. It asked participants to choose one of four definitions of "emergency medical condition." In addition, people were asked to determine which of 30 chief complaints they thought needed care in the ED. Demographic information was also collected. A second set of surveys asking the same questions was conducted among nonemergency healthcare providers at hospitals. Healthcare worker was defined as an MD, RN, LVN, or PA. A total of 1,018 members of the public and 126 healthcare workers completed the survey. EMC definitions selected by the public were: 1) an abbreviated federal EMTALA definition: a condition that may result in death, permanent disability, or severe pain (48.7%); 2) the federal definition plus other conditions preventing work (3.0%); 3) the federal definition plus any other conditions outside business hours (16.5%); and 4) any condition at any time as determined by the patient (31.6%). HCWs selected the following: definition 1 (71%); definitions 2 and 3 (0%); and definition 4 (27%). Definitions 1 and 3 were statistically different when comparisons were made between the public and HCWs. On the question of which of the 30 chief complaints needed care in an ED, agreement was seen between the public and HCWs for severe abdominal pain (94% vs. 99%, respectively) and severe chest pain (96% vs. 99%, respectively). However, the two disagreed on the need for ED care for severe headache (58% vs. 91%, respectively); mild chest pain (51% vs. 79%, respectively); and difficulty breathing (77% vs. 98%, respectively). No significant difference in opinions on the need for ED care was seen for some minor conditions: mild headache, sore throat, cough, flu symptoms, minor foot problems. No significant differences in answers occurred when age groups, occupations, or locations were compared. In conclusion, the public has split views concerning the general definition of an emergency medical condition. Approximately half uses a conservative federal definition, and half uses patient self-determined need as the definition. Data on which specific conditions need ED care provide additional insight on agreement between the public and HCWs on most problems. Both groups agree that many perceived minor medical complaints do not require ED care.
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Affiliation(s)
- R W Derlet
- Emergency Department, University of California, Davis, Medical Center, Sacramento 95817, USA
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Neely KW, Norton RL, Schmidt TA. State insurance commissioner actions against health maintenance organizations for denial of emergency care. PREHOSP EMERG CARE 1999; 3:19-22. [PMID: 9921735 DOI: 10.1080/10903129908958900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. METHODS Telephone survey of all state insurance commissioners (SICs). The specific question asked was: "What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?" Each office was contacted at least three times. RESULTS Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. CONCLUSIONS Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.
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Affiliation(s)
- K W Neely
- Department of Emergency Medicine, Oregon Health Sciences University, Portland 97213-3098, USA.
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