THE VIRGINIAN-PILOT
Copyright (c) 1995, Landmark Communications, Inc.
DATE: Friday, July 14, 1995 TAG: 9507140411
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: BY MARIE JOYCE, STAFF WRITER
LENGTH: Long : 123 lines
The young woman showed up at the emergency room complaining of chest pain. It felt, she said, like someone was sitting on her chest. She was afraid she was having a heart attack like the one that had killed her 56-year-old mother a few months before.
The emergency room staff did an X-ray and electrocardiogram. She had muscle pain, not heart trouble.
Her insurance company said it wasn't a real emergency. They refused to pay for her visit.
Scenarios like this one, which occurred at a Hampton Roads hospital, happen daily at local emergency rooms, say the doctors who staff them.
Virginia just became one of three states to enact a law intended to regulate these cases. The measure, which went into effect July 1, says insurance companies can't simply reject emergency-room bills for minor ailments if the patient had good reason to believe he was suffering a true medical emergency.
As more and more health care is handled by health maintenance organizations and managed-care plans, emergencyroom doctors, patients and insurers are facing a dilemma.
On one hand, doctors say, a person who reasonably believes he's in trouble should get reimbursed if he runs to the emergency room, even if the doctor decides the problem is minor.
On the other hand, say insurers, many people visit the ER for minor things that could be handled at an urgent care center or doctor's office. The ER visit is a lot more expensive, and health insurance consumers end up paying more in the long run.
``Sure, it's easy for the HMO to come back and say, `That wasn't really an emergency,' '' said Jeffrey Smith, a doctor with Emergency Physicians of Tidewater, the group that staffs most local hospital ERs. ``They're not having to stand face-to-face with the patient, having to say, `Send Grandma home.' ''
Smith gives an example: ER doctors are taught to watch for a phrase like ``it's the worst headache I've ever had,'' he said. It could indicate a hemorrhage or a stroke. It could be just a headache. But the only way to find out for sure is with a computerized axial tomography, or CAT scan, a test that uses X-rays to construct highly detailed images of the inside of the body.
``It's really the only test that tells you much of anything that's worthwhile. On the other hand, it's also an $800 test,'' he said. ``These are a lot of judgment calls that aren't easy to make.''
In managed care, insurance companies try to control rising health-care costs by emphasizing prevention and by using the least expensive treatment that will work. It is still a relatively small part of health care in Hampton Roads. Only 10 to 20 percent of local residents get their health insurance from a health maintenance organization or other managed care plan. But most people in the health-care business expect managed care's influence to grow.
David Pitrolo, a doctor with the group that staffs the emergency room at Chesapeake General Hospital, says insurance companies often don't look at emergencies from the patient's perspective.
A patient's chest pain may be caused by indigestion, but ``it's hard even for a doctor to tell'' until he runs tests like an EKG. ``There's no way the patient could have known that.''
But the doctors concede there have been - and still are - abuses.
Earaches, the flu, small cuts, and minor sprains and strains are the most common nonemergencies that bring people to the ER, said Sharon Metz, vice president of medical care management for Sentara's HMOs.
When that happens, the emergency room bill is three to four times as high as the same treatment would be at a doctors' office or urgent care center, said May Fox, executive director of the Virginia Association of HMOs.
``The emergency room is . . . probably the most expensive setting to receive what is basically primary care.''
Metz's department at Sentara identifies and counsels people who chronically misuse the emergency room. ``Nine out of 10 times we can resolve the issue if we let them know if they continue to seek services, they (the bills) won't get paid,'' she said.
Patients aren't trying to rip off the system, she says. Often, they don't understand how the system works. Or it's hard for them to get to the doctor during the work day. Or the hospital is more convenient than an urgent care center.
``Some of it is learned behavior. For so (long), we thought our only source of . . . health care in the middle of the night was the emergency room, because we know it's open 24 hours a day.''
Sentara runs an ``After Hours'' service for people who think they may need medical help after their doctor's office has closed.
Nurses staffing the phones question the caller about the medical condition, following a prescribed set of questions. If the nurse believes the medical condition is urgent and life-threatening, he instructs the caller to call 911.
For a nonemergency, he gives advice on how to handle the problem at home.
If a person is told not to go to the emergency room but goes anyway, Sentara - like most insurance companies - will review the case before deciding whether to pay.
It's not just a question of saving money, Metz said. If a patient shows up at the emergency room with a minor cut, he may wait for hours as people with serious injuries go in ahead of him.
Doctors also say they don't want the emergency room clogged with nonemergencies.
But ``someone who's having chest pain, I'm not sure they should be at (an urgent care center),'' said Pitrolo, the Chesapeake doctor. ``If they find something, you're in the wrong place.''
Doctors are waiting to see the results of the new law.
In Maryland, the first state to pass such a law, it seems to be working, said Michael Bono, a doctor with Emergency Physicians of Tidewater. Bono worked for passage of the Virginia legislation. Arkansas is the only other state to adopt similar language.
``The first time we see a denial, and that (case) is legitimate, we're going to take them right to court,'' Bono said. ``We will give the HMOs one chance.''
Pitrolo says the arguments may intensify next year, when all Medicaid patients in Hampton Roads are put in an HMO-type program.
Medicaid, the government insurance program for the poor, accounts for about 20 percent of emergency room visits, said Pitrolo. Insurance companies have said that many of those visits are unnecessary. ILLUSTRATION: Color staff photo by VICKI CRONIS/
Dr. David Pitrolo, who works at Chesapeake General Hospital, says
it's important for patients to be able to visit an emergency room if
they really think they need to go.
KEYWORDS: EMERGENCY ROOM HMO HEALTH INSURANCE MEDICAL INSURANCE by CNB