THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Sunday, November 3, 1996 TAG: 9611030035
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY MARIE JOYCE, STAFF WRITER
DATELINE: NORFOLK LENGTH: 78 lines
Dr. Frank Counselman asked other doctors to consider this scenario:
A woman develops a urinary tract infection late Friday. Her doctor tells her he can't see her until Monday. She becomes so uncomfortable that she decides to go to the emergency room.
But if she does, the woman's health maintenance organization will refuse to pay the bill because the condition was not a clear medical emergency.
That's not fair, said Counselman, who practices at Sentara Norfolk General Hospital.
His colleagues apparently agreed.
Medical Society of Virginia members, at the urging of emergency room doctors, voted Saturday to seek laws or regulations forcing health insurance companies to reimburse the initial examination of patients who visit emergency rooms.
The emergency room issue was one of dozens addressed at the society's annual meeting, which ends today at the Waterside Marriott. The meeting is largely a forum for the society to take public positions on health care issues and develop priorities for lobbying bythe group's political action committee.
Many of the issues concerned ways to deal with managed care, a growing form of health insurance that tries to keep costs low by, among other things, limiting hospital visits and treatment by expensive specialists.
A hallmark of that cost-cutting is encouraging people to see their family doctor for treatment of non-emergency conditions, rather than using a hospital emergency room, which costs much more. This has been a particular goal of companies running new HMOs that serve poor families on Medicaid.
This goal has caused friction with emergency room doctors before.
Last year, Virginia enacted a law saying insurance companies can't reject an emergency-room bill for a minor ailment if patients had good reason to believe they faced true medical emergencies. So a person who thought her chest pains signaled a heart attack is covered, even if the pains turn out to be indigestion.
Now, emergency room doctors want more restrictions on the HMOs. They believe the companies should pay for the initial examination of anyone who comes to them, even those who know they aren't in danger.
Counselman said emergency room doctors have no choice but to take such cases. Federal law requires them to screen anyone who walks through their doors.
Patients often don't have a choice, either, he said. Some insurance plans don't offer clinics on weekends and evening hours.
Some won't pay for a patient to visit an urgent care center unless it's an emergency, Counselman said. And because the HMOs save money by not paying for weekend treatment, ``there is no incentive for the HMOs to change the way they practice,'' he said.
``We don't think the patients should be penalized for this.''
But Dr. William J. McAveney said that forcing insurers to pay for screenings will encourage misuse of the emergency room and drive up costs for everyone else on the plan.
Some patients make no effort to see a family doctor and come to the emergency room for a complaint as minor as athlete's foot, said McAveney, a pediatrician who works for an HMO, Kaiser Permanente, in Springfield.
The insurance company designed policies to discourage that abuse, he reminded colleagues. One bill might persuade patients to use their family doctors next time.
And he noted that many HMOs offer after-hours care. His company, for instance, staffs a clinic until 11:30 p.m. every day, including Christmas.
Among the dozens of other matters addressed Saturday, the doctors voted to do the following:
Support mandatory testing of pregnant women - and infants and children of HIV-positive women - for the virus that causes AIDS, so that children who need it can get early treatment.
Study the ethical issue surrounding some types of managed care payment policies, and consider lobbying to change them.
Lobby to require health plans to provide notice of reimbursement changes to doctors and patients 180 days in advance.
Support laws that would require insurance companies to pay for breast reconstruction after mastectomy.
Encourage anti-discrimination laws to protect patients receiving genetic testing.
Work for a higher tax on cigarettes.
KEYWORDS: MEDICAL INSURANCE by CNB