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The Problem With Anthem Refusing to Cover Non-Urgent ER Visits

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Sometimes the news isn’t as straightforward as it’s made to seem. Paige Wyant, The Mighty’s associate chronic illness editor, explains what to keep in mind if you see this topic or similar stories in your newsfeed. This is The Mighty Takeaway.

As a person with an autoimmune disease whose body seems partial to wacky symptoms and unusual presentations, I am no stranger to the emergency room. I end up in the ER at least once a year, usually more, when my chronic illness gives rise to acute issues (such as infections) that need attention stat.

I don’t enjoy going to the emergency room (does anyone?) – in fact, it’s an experience I dread and try to avoid at all costs. But there are times when the ER is the best option I have for managing my health and keeping any sudden issues safely under control.

However, new policies being pushed out by Anthem Blue Cross/Blue Shield threaten to take the ER away as a viable option – not just for me, but for every American that counts on them for health insurance.

Last summer, Anthem BCBS enacted a new insurance policy for members who live in Georgia, Missouri or Kentucky that makes them responsible for covering the cost of any ER visit Anthem determines to not be an “emergency.”

Anthem defines an emergency as:

A medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that not getting immediate medical care could result in: (a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Then, earlier this year, Anthem announced it’s rolling out its emergency coverage policy in three additional states – New Hampshire, Indiana and Ohio – with potentially more states to follow.

“Save the ER for emergencies — or cover the cost,” a letter sent to Blue Cross and Blue Shield of Georgia members, obtained by NBC News, states. “[S]tarting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”

People in these states are already being affected by Anthem’s new policies. Last summer, a 27-year-old woman in Kentucky went to the ER with acute abdominal pain, fearing she may have appendicitis. When the cause turned out to be ovarian cysts, Anthem denied coverage, leaving her with a hospital bill for $12,596.

Anthem says that reducing unnecessary ER care is meant to be a cost-cutting strategy. The policy will not apply to patients who are 14 or younger, don’t live within 15 miles of an urgent care center or if the visit takes place on a Sunday or holiday.

Although Anthem claims this policy is only aimed at patients who seek treatment at the ER for minor ailments, there are some major oversights we need to address.

Anthem’s policy essentially asks patients to distinguish between emergencies and non-emergencies. But if the patient is not a doctor or medical professional, how can they know for sure? Maybe the abdominal pain you’re experiencing is just a buildup of gas – or maybe it’s appendicitis or a life-threatening infection. But you don’t know that until after you’ve been assessed by a doctor.

And what happens if this extreme abdominal pain arises on a Friday evening? Do you “tough it out” for the weekend and wait until Monday morning to call your doctor? What if your doctor is booked solid, and can’t get you in for a week? Do you wait? Maybe the issue is benign and will resolve on its own in a day or two. Maybe not. In either case, wouldn’t you rather be safe than sorry?

With the very real possibility of having to pay the entire cost of the visit hanging over one’s head, many may be dissuaded from seeking medical attention. 

This is dangerous. People shouldn’t be afraid to seek medical attention because of the potential costs involved. But Anthem’s new policy may be especially harmful to those like me who live with chronic illness.

It may seem contradictory that patients with chronic conditions are affected by a policy concerning ER visits for acute medical needs. But if you have a chronic illness, you probably know all too well how common (and critical) ER visits can be.

Here’s what Anthem needs to understand about the importance of ER visits for chronically ill patients – especially if the reason for our visit doesn’t fall under their definition of “emergency”:

1. “Non-emergency” issues can actually be critical for patients with chronic illness.

For people with chronic conditions don’t function at the same capacity as those who are generally healthy. Some illnesses or medications (such as immunosuppressants) can weaken the body’s ability to fight off infections, making the common cold a full-blown crisis for someone with a weakened immune system.

If I catch something or believe I have an infection, my first response is to call my doctor and try to get an appointment as soon as possible. But, if I am unable to get an appointment in a timely manner for any number of reasons (it’s the weekend, her schedule is full, I’m traveling, etc.), I am often advised to seek treatment at the ER.

Waiting a few days to see a doctor for cold symptoms, for instance, may not be a huge deal for some, but it could be very dangerous for me because of my suppressed immune system. If I’m not proactive in doing everything I can to manage the symptoms or address the root cause of the issue (if possible), my condition could decline rapidly.

Anthem may be hoping to save money with their new policy by encouraging me to wait for a regular doctor appointment rather than seek emergency treatment, but ultimately, it would probably cost more if I waited and allowed the issue to get more out of hand – likely requiring even more treatment or medications or follow-ups – than if I had gone to the ER early on and taken care of the issue quickly.

Bottom line: What may not seem like an “emergency” health issue for the general population could very well be an emergency health issue for someone with chronic illness. Every person and situation is different, and it’s unfair to punish people for trying to be proactive about their health.

2. It can take a really long time to get in to see our doctors – time we may not have.

Health issues that may not be critical for most people can be critical for patients with chronic illness due to compromised immune systems or bodies that don’t function properly. When we get sick, time is often of the essence.

Unfortunately, it’s not always feasible to get in to see your doctor or specialist right away. Some have waiting lists that are weeks- or months-long, and some may not even be located in your city or state. (I live nearly 1,500 miles away from my primary specialist.) I’ve had specialists advise me more than once to seek treatment in the ER when they weren’t able to get me in as quickly as I needed to be seen.

Would the health issue I was experiencing be classified as an “emergency” according to Anthem? In most cases, probably not. But if a trained specialist is telling me I need to go to the ER, my insurance company shouldn’t be suggesting my doctor was wrong by punishing me with the full responsibility of the costs.

3. Flare-ups happen.

A flare-up occurs when some or all of chronic illness symptoms increase in severity. Even those on various medications or following treatment protocols can have periods where their symptoms spike out of control.

There have been countless times in my life where a symptom I have been dealing with for days suddenly gets a lot worse. My illness is unpredictable, and I can literally go from feeling somewhat decent to feeling as though I’m on my deathbed overnight. When my body crashes so quickly, I don’t really have an opportunity to “plan ahead” or make an appointment with a doctor. By the time I know I’m going to need medical attention, I need it right then and there.

Being so sick or in so much pain that you feel you can’t go on should be considered an emergency. Whether your symptoms are causing you to reach a physical or mental crisis point, you shouldn’t have to worry about the potential consequences of seeking help.

In her article “Going to the Emergency Room When My Pain Is ‘Too Much,’” Mighty contributor Louise Ansell perfectly explains why someone with chronic pain might go to the ER:

I would not be asking for help if I didn’t think I needed it. I would not be asking for increasingly stronger painkillers if I had not tried everything in my power to avoid it. I only go to the emergency room when I am absolutely desperate. When I have taken a concoction of medications that would knock most people out. […] the ER is an absolute last resort, for when I’m sitting in my room in so much pain I cannot bear it anymore.

But, if it turns out that symptoms are not life-threatening – in other words, they don’t fit Anthem’s narrow definition of an “emergency” — then you would have to pay a ridiculous amount of money for not having the foresight to know exactly how serious your symptoms were.

And that can be damaging – physically, mentally, emotionally and financially.

Cutting costs should never come before the health, safety and comfort of patients. Everyone deserves to seek the treatment and care they need without the fear and stress of receiving a massive bill.

Getty Image by Chad Baker/Jason Reed/Ryan McVay

Originally published: March 16, 2018
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