By Pat Anson, Editor
Reducing the cost of healthcare is a major goal for insurers, providers and patients, but some physicians say the state of Rhode Island is taking things too far by discouraging some patients from getting their pain treated.
The state’s Executive Office of Health and Human Services has issued a report that identifies $90 million in annual savings “by preventing non-emergency visits” to hospital emergency rooms. Chest pain is listed as “the greatest opportunity for savings” while back pain, abdominal pain and headache are considered “potentially preventable" reasons for emergency room care.
“While many people associate ‘chest pain’ with ‘heart attack’, a truly emergent and serious condition, the majority of those who present to the emergency room with chest pain and are not admitted to the hospital are not experiencing a heart attack,” the report says.
In Rhode Island, 46% of emergency room visits were considered potentially preventable for privately insured patients and 70% of the visits for Medicaid patients.
“A potentially preventable emergency room visit is when a patient goes to an emergency room for a health condition that could have been treated in a non-emergency setting or prevented by keeping them healthier earlier on. Treatment in an emergency room is generally more expensive than a primary care visit,” according to the report.
The average cost of an emergency room visit in Rhode Island varies considerably, from $368 for a Medicaid recipient to $1,154 for someone with private insurance.
The American College of Emergency Physicians (ACEP) calls the report irresponsible and flawed, because it relies on data about patients’ final diagnoses, not their presenting symptoms. That analysis does not take into consideration the national "prudent layperson" standard in the Affordable Care Act (ACA), which says emergency visits must be covered by insurance companies based on the patients' symptoms, not their final diagnoses.
"It is very alarming that a report like this is being issued that directly undermines language in the ACA and patients' responsible use of the emergency department," said Jay Kaplan, MD, president of ACEP. "Patients never should be forced into the position of self-diagnosing their medical conditions out of fear of insurance not covering the visit. This applies 20/20 hindsight to possibly life-threatening conditions — such as chest pain — and it violates the national prudent layperson standard designed to protect patients' health plan coverage of emergency care."
Data in the Rhode Island report also does not correlate with the latest national data on emergency visits from the CDC, which found that 96 percent of emergency patients needed medical care within two hours.
"A report like this only serves to potentially scare patients away from the emergency department when they may need it most," said Christopher Zabbo, DO, president of ACEP's Rhode Island Chapter. "Both harmless and deadly conditions often have the same presentations. Asking patients to make that determination while at home, anxious, and with inadequate information, is a recipe for disaster."
“I do all I can to stay away from our hospitals unless it is a planned surgery. I arrive with all my records, educated on my condition and find they (doctors) are immediately turned off due to my complications,” said Ellen Lenox Smith, a Rhode Island resident who suffers from Ehlers Danlos syndrome and is a columnist for Pain News Network. Ellen recently wrote about some of her bad hospital experiences and how she learned to avoid future ones. (see”How to Stop Hospital Horrors”).
According to the CDC, stomach and abdominal pain were the number one reason for patients to visit an emergency room in 2011, followed by chest pain, fever, headache, cough and back pain.