Anthem, Inc. says it is trying to save money while getting its patients more engaged in their health care by implementing a new emergency room policy that some critics say is too harsh. The policy, implemented in several states, denies coverage of ER care for certain conditions that Anthem says would be better treated at a physician’s office or urgent care center. But physicians are up in arms about it, saying the policy is dangerous to patients’ health — and even their lives.

Anthem rolled out the policy June 1 in Missouri and July 1 in Georgia in the individual market after a 2015 effective date in Kentucky. “Since then, we’ve seen a reduction in Kentucky members who had repeat avoidable ER claims,” according to Anthem spokesperson Joyzelle Davis. “And we are seeing only a small percentage of claims in the state being denied as unnecessary ER use cases.”

The health plan is considering expanding the policy to other markets as well, she says.

Cathryn Donaldson, director of communications and public affairs at America’s Health Insurance Plans (AHIP), tells AIS Health that plans work hard to educate members on the most appropriate venues for care. This includes providing updated provider directories, offering new technologies such telehealth services, and promoting value-based, coordinated care.

“Going to an ED versus an outpatient center for a condition that is not an emergency may take a patient hours longer and, typically, costs four times more than treatment at an outpatient facility,” she says. “In fact, visits to the ED for conditions that aren’t true emergencies waste more than $38 billion a year, driving up health care costs and premiums.”

The Anthem policy does not apply to patients under 14 years old, Sunday or holiday ER visits, or situations where the patient was referred to an ER by a physician. It also doesn’t apply to members who live more than 15 miles from an urgent care center, Davis says.

Anthem Seeing More ER Misuse

The reason for the new policy, according to Davis, is Anthem is seeing an uptick of members going to the ER for conditions that shouldn’t be treated there, including for itchy eyes, athlete’s foot and suture removal.

“In the end, we want our members to establish a good relationship with their primary care physicians who can guide them on their health journey,” she says. “That’s really at the core of it.”

Davis says Anthem’s policy is also in response to the availability of more alternatives to ER care for Anthem members, which includes a 24/7 nurse line that members can call and an Anthem Anywhere app that helps members find nearby network urgent care and walk-in clinics. Anthem also offers telehealth services for a primary care physician copay to its members, with licensed doctors available 24/7.

In addition, via Enhanced Personal Health Care, a value-based contracting program, Anthem encourages network primary care physicians to offer longer office hours and to follow up with patients who went to the ER to make sure they call their doctor first next time. More than 64,000 providers participate in Anthem’s Enhanced Personal Health Care program, caring for 5.5 million Anthem members, Davis says.

Anthem’s ER policy is based on a list of “avoidable” or non-emergency conditions, which it developed with four board-certified emergency physicians, Davis says. “If a member chooses to receive care for common ailments in the ER when a more appropriate setting is available, their claim may be reviewed by an Anthem medical director using the prudent layperson standard” — a standard that requires insurance coverage based on a patient’s symptoms, not their final diagnosis, she says. “In reviewing the claim, the medical director considers the member’s presenting symptoms that may appear to be an emergency even if the diagnosis turned out to be a non-emergency ailment.”

Avoidable or Emergency Symptoms?

The list is what has physicians so concerned. In May, the American College of Emergency Physicians (ACEP) and its Missouri chapter said Anthem’s list of medical diagnoses “is a clear violation” of the national prudent layperson standard, which is codified in federal law including the Affordable Care Act and is also law in more than 30 states.

ACEP is concerned that under Anthem’s new policy, a patient who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, could be denied coverage if the final diagnosis does not turn out to be an emergency.

“Health plans have a long history of not paying for emergency care,” says Rebecca Parker, M.D., president of ACEP. “For years, they have denied claims based on final diagnoses, instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as health care reforms are being debated again, insurance companies are trying to reintroduce this practice.”

ACEP claims that some of the diagnoses on Anthem’s list of 2,000 avoidable conditions are symptoms of medical emergencies, including chest pain on breathing, which could be a life-threatening pulmonary embolism; acute conjunctivitis, which if caused by gonorrhea can cause blindness; or influenza, which kills thousands of people a year.

“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance,” Parker says. “The vast majority of emergency patients seek care appropriately, according to the CDC, and often times should have come to the ER sooner.”

Parker suggests Anthem may need to “manage” patients who use the ER incorrectly, but “in an emergency situation, it’s not the time.”

ACEP is skeptical that Anthem’s policy is for the well-being of its members. “The diagnoses they’re picking are not low-hanging fruit,” she says. “In the last 10 years, what we’ve been seeing is every strategy is about increasing profits. In our mind, it’s about money.”

Georgia’s ACEP chapter also came out against the policy in a June 1 statement. “We treat patients every day with identical symptoms — some get to go home and some go to surgery,” said Matt Lyon, M.D., president of Georgia’s ACEP Chapter. “There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.”

The American Medical Association (AMA) also got into the fray. In a June 29 letter, AMA Executive Vice President and CEO James Madara, M.D., urged Anthem CEO Joseph Swedish to put an end to the policy.

“The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die….[The policy] also reduces the value of health insurance policies on which patients have spent thousands of dollars to have access to care, including emergency care,” Madara wrote.