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At the UCSF Emergency Department, doctors are seeing a\u00a0dangerous trend: insurers refusing to pay for care after the fact based on whether a patient\u2019s final diagnosis appears \u201cserious enough.\u201d<\/p>\n
Lea Suzuki\/S.F. Chronicle<\/p>\n
Imagine this: You\u2019re out for a walk and feel an agonizing pain in your chest. You sit on a nearby bench and wait for the pain to subside. But it doesn\u2019t.<\/p>\n
The pain gets worse and you start to panic \u2014 could this be a heart attack? The pain feels serious enough that you need to get to a hospital emergency department to find out.<\/p>\n
Once there, doctors aren\u2019t sure what\u2019s wrong, either. It could be a heart attack, or it could be something less serious. They can\u2019t know for sure. So they run tests \u2014 electrocardiogram, blood work, imaging \u2014 to rule out life-threatening causes. Thankfully, those tests turned out normal. Having ruled out the potentially life-threatening causes of your pain, you\u2019re discharged with a diagnosis like \u201cchest wall pain.\u201d<\/p>\n
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You\u2019re shaken but relieved. Better safe than sorry. This is why you have health insurance.<\/p>\n
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<\/p>\n Add Preferred Source<\/p>\n <\/a><\/p>\n At the UCSF\u00a0Emergency Department, where I work<\/a>, we\u2019re starting to notice a dangerous trend: insurers refusing to pay for emergency care after the fact based on whether a patient\u2019s final diagnosis appears \u201cserious enough.\u201d<\/p>\n For emergency physicians like me, this is a familiar and troubling pattern. Years ago, insurers attempted to deny coverage for visits deemed \u201cnon-emergent\u201d based on discharge diagnoses. But emergency care doesn\u2019t work that way. Patients don\u2019t arrive with diagnoses \u2014 they arrive with symptoms, often indistinguishable from life-threatening conditions.<\/p>\n Article continues below this ad<\/p>\n While insurers might have you believe that many emergency department visits are unnecessary and avoidable and contribute to high health care costs, this is a myth.<\/p>\n The U.S. health system is over capacity<\/a>, and often the emergency department is the only open door.\u00a0<\/p>\n Most patients are in the emergency department these days not because they want to be, but because they need to be. The hallways where I work \u2014 and those of many emergency departments across the country \u2014 are crowded with patients in stretchers and chairs. Our waiting rooms are full of additional sick patients who are frustrated that they have not yet been seen. We are a one-stop shop for heart attacks, strokes and trauma, and for people in acute mental health crises, who have severe substance use disorders and who are at the end of life from metastatic cancer.<\/p>\n The patients we see have become more seriously ill, with recent research<\/a> showing that from 2012 to 2022, nonurgent emergency department visits decreased by over 50% while severe visits increased by nearly 35% and critical visits by over 75%.<\/p>\n Despite this, health insurance companies appear to be making another attempt to refuse to pay for emergency care.\u00a0\u00a0\u00a0<\/p>\n Article continues below this ad<\/p>\n I have been an emergency physician for over two decades and also a researcher.\u00a0Earlier in my career, insurers attempted to deny coverage for emergency department visits if the discharge diagnosis \u2014 the diagnoses we give a patient after we have ruled out all the possible emergency conditions they might have during their visit \u2014 was deemed to be \u201cnon-emergent.\u201d<\/p>\n That might sound reasonable until you understand how diagnoses in our department actually work.<\/p>\n The insurers did not want to pay for the visit if they deemed chest wall pain not to be an emergency. But the only way we could arrive at that diagnosis was by doing high-intensity tests to rule out a heart attack and other serious medical problems. This seemed absurd: were they trying to discourage people with heart attack signs from coming to the emergency department?<\/p>\n In 2013, colleagues and I published a study<\/a> in the Journal of the American Medical Association that used administrative data to analyze emergency department visits from start to finish. We found that among visits with the same presenting complaint as those ultimately given a \u201cnon-emergency\u201d diagnosis based on discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. In other words, what insurers were proposing was not safe.<\/p>\n For a time after that report, it seemed as if insurers had backed down.<\/p>\n Article continues below this ad<\/p>\n But now, in many instances across the healthcare spectrum, it appears insurers are beginning to use AI to resuscitate and automate this same flawed logic. Algorithms scan discharge diagnoses and\u00a0automatically downcode visits<\/a> \u2014 even when physicians performed extensive testing to rule out life-threatening illness.<\/p>\n Emergency departments are one of the last places in the American health system where anyone can seek care at any time, regardless of ability to pay. Physicians are legally and ethically obligated to evaluate every patient for life-threatening conditions \u2014 not to guess who is worthy of care after the fact.<\/p>\n Because the entire American health system is overstressed, emergency departments have no off valve. Patients are facing longer wait times, and we\u2019re seeing increased violence toward staff. Refusing to pay for the care we provide can lead to hospital closures, cutting off a vital source of care for communities. Research has shown that emergency department closures lead to increased mortality at neighboring hospitals.<\/a><\/p>\n Guest opinions in Open Forum and Insight<\/strong> are produced by writers with expertise, personal experience or original insights on a subject of interest to our readers. Their views do not necessarily reflect<\/strong> the opinion of The Chronicle editorial board, which is committed to providing a diversity of ideas to our readership.<\/p>\n