By Paul Kivela, MD, MBA, FACEP
President of the American College of Emergency Physicians
Health insurance companies have a long history of denying coverage for patients and using scare tactics to prevent people from seeking emergency care. They have been paying less for medical care and creating narrow networks of hospitals and physicians, making it more likely that patients will be out-of-network.
If the insurance industry was correct, hospitals with emergency departments would be posting record profits and opening new facilities all over California and the entire nation, and there would rarely be waits for patients. The reality is these hospitals are closing or in threat of closure, margins are thin, and hospitals and medical groups are cutting staff.
At the same time, insurance companies are posting record profits in the billions while average revenue to medical providers is plummeting and patients are forced into financial ruin by putting them in high-deductible plans that many cannot afford. Many people don’t realize how little insurance coverage they have until they need emergency care — and then they are shocked at how little their insurance companies pay
Insurance companies are taking advantage of hospital emergency departments, because they have a federal mandate to provide care, regardless of insurance coverage or ability to pay, giving negotiating power to the insurance industry.
Unfortunately, health insurance companies are ignoring a real solution to "surprise" medical bills and misleading customers and the public when they blame physicians. The Fair Health database, which was developed in response to an insurance company that was fraudulently calculating payments for emergency care, is the best mechanism available to ensure transparency and to make sure insurance companies provide fair payments.
Instead, the insurance industry is using scare tactics to prevent people from seeking emergency care. For example, Anthem Blue Cross-Blue Shield has implemented a dangerous policy in six states to deny coverage for emergency patients based on secret lists of diagnoses.
This policy expects people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix. After repeated unsuccessful efforts to work with Anthem and explain the concerns and how it violates a federal standard that requires insurance companies to pay, based on symptoms, not final diagnosis, ACEP and the Medical Association of Georgia filed suit in federal court in an effort to compel the insurance giant to rescind its policy
I’m surprised that a health care finance expert would suggest applying the Maryland model in California as Maryland pays roughly 125 percent of Medicare not just by commercial plans but also by Medicaid and Medicare. That would likely cost the State of California billions and potentially bankrupt the state.
In addition, the editorial refers to data from California, but they are insurance company data, which are neither identified nor available for examination, showing the lack of transparency by the health insurance industry.
The author also fails to acknowledge he is the Blue Cross Blue Shield Chair in Healthcare Finance at his university
I believe it is important for universities to investigate whether their faculty members that take health insurance company grants understand healthcare financing and actual payment practices or whether they are purposefully misusing the data and confusing macro and microeconomics to obfuscate the truth.
My hope is that universities across the country will uphold academic integrity and refuse to let their faculty members accept industry payoffs. Emergency physicians are also calling on insurance companies to pay fairly and put patients before profits. And we are calling on state regulators to uphold and enforce the laws that require fair payment and protect patients’ access to quality emergency care.