EMERGENCY CARE: Study Finds Many Plans Unclear
HMOs offer widely varying instructions about when enrollees should seek emergency care and relatively few "include chest pain and stroke symptoms in their definitions of emergencies," according to a study in the Annals of Emergency Medicine. Keith Neely of Oregon Health Sciences University reviewed the emergency care instructions issued by 15 West Coast HMOs in 1996 to see if they had deterrents to emergency care. He found that two out of three HMOs "made specific mention of ER use in their materials" and four out of 15 "suggested calling the patient's primary care physician or an 800 number first." Four did not mention either calling 911 or going to the emergency room, the Washington Times reports. Just "six of the plans spelled out symptoms of a heart attack as an emergency condition," while only "two spelled out stroke symptoms." Neely also found that the definitions of what constituted an emergency were "often vague and bureaucratic" and only one suggested that the primary factor in deciding whether to seek emergency care should be the person's own "perception of his condition." Neely said, "This study argues for a prudent layperson definition of medical emergency. ... This standard will place the ability to decide when an emergency condition exists with the patient, not the payer, and help members avoid being caught between the instructions to contact a gatekeeper ... and widely publicized directions to call 911 right away." However, American Association of Health Plans spokesperson Susan Pisano said that according to its code of conduct, HMO enrollees should be informed to call 911 or go to the ER if they believe their life or health is threatened and that their plan should cover such services. She added, "Where we've gotten off track is with additional care for unrelated conditions that takes place after the original condition has been treated and stabilized, like a diabetic workup for a patient that came in with a broken leg" (Bowman, 7/25).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.