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Bruce Lo: Payment questions add more pressure in the ER

http://www.richmond.com/opinion/their-opinion/guest-columnists/bruce-lo-payment-questions-add-more-pressure-in-the-er/article_7348ad3c-66ef-55ac-88f4-90ad5e31cab8.html 

Imagine going into business knowing that about half of the work you do will be done for free. Not only that, the government mandates that you perform your work and that your business has to remain open all the time (yes, even weekends, nights, and holidays).

This is the reality that Virginia’s emergency departments face. As emergency physicians, we are not only morally and professionally committed, but required under federal law to provide care to anyone in need of treatment regardless of the individual’s ability to pay.

The federal government has created this safety net for the uninsured and underinsured — a population that has in recent years included many middle-income households. Despite the mandate of care, there is no mandate of coverage beyond some assistance from Disproportionate Share Hospital (DSH) payments, which cover hospital care for Medicaid and uninsured patients. However, no similar program exists for physicians. Furthermore, health insurers are reimbursing at rates far below the customary payment and some are even starting to deny claims for emergency department visits altogether — after-the-fact.

Imagine having chest pain during dinner, but you are unsure whether it is a heart attack or indigestion. Because of concerns about insurers denying payments for seeking care in the emergency department if the final diagnosis ends up being “non-emergent” — such as indigestion — people are avoiding care until it is too late.

Now imagine that indigestion was actually a heart attack. As a result, patients are not receiving early interventions that can save lives and help curb further health-care costs down the line.

In denying payments to hospitals and physicians, insurers are violating the “Prudent Layperson” standard, which was defined by law in the late 1990s as an individual who possesses an average knowledge of health and medicine and, therefore, can make decisions based on their symptoms as to whether they should seek medical care.

This standard establishes the legal criteria that insurance coverage is based not on the final diagnosis, but on whether a prudent person might anticipate serious impairment to his or her health in an emergency situation.

A poll from the American College of Emergency Physicians found that one in three Americans have delayed or even avoided emergency care out of concerns over cost, including those with insurance. As a result, health-care providers — and often emergency physicians — bear the brunt of providing costly care and maintaining availability to it 24/7/365.

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The issues of uncompensated and undercompensated care are not about threats to our livelihoods as physicians — they are about threats to patients. When care goes unpaid, the ability to provide high-quality service declines: We can’t hire the best physicians and staff, invest in the latest treatments and procedures, or build the most modern health care and trauma facilities.

Our emergency care system is not sustainable.

Faced with mounting pressures and shouldering the burden of uncompensated care, emergency departments will be forced to cut back on services — or worse, close down completely.

Emergency physicians will leave the specialty for greener and less stressful pastures. Specialists covering the emergency departments will also become less available at hospitals, worsening the gaps in patient care.

So, what can be done?

The lack of a system to ensure fair benefit payments to providers has allowed insurers to underpay the fair value of emergency services, creating the need for health-care providers to bill patients for the balance on sometimes expensive health-care bills.

“Balance billing” ensures the ability to provide patient-care services where there are no enforced laws or regulations requiring health plans to pay appropriate benefits for emergency-care claims at rates sufficient to maintain the financial viability of the nation’s emergency care system.

For patients who are out-of-network and may receive such bills, we look to create a payment model that protects patients and ensures physicians are fairly compensated.

Emergency physicians have many other avenues to practice medicine, but we choose this specialty because we love what we do: helping those in need, regardless of an individual’s socioeconomic status.

Let’s work together and encourage our policymakers and health plans to find a way to fix a broken system. Together, we can build a system that delivers great care for all.

Bruce Lo, M.D., is president of the Virginia College of Emergency Physicians. He is an emergency physician and medical director of the Department of Emergency Medicine of Sentara Norfolk General Hospital.