'Gatekeeping' shuts doors on ER patients

Scream as loud as you want, but severe pain might not be enough to convince your health insurance company that your visit to the emergency room should be on them. According to a study conducted by researchers from the Hospital of the University of Pennsylvania and Oregon's Sacred Heart Medical Center, insurance companies may be blindly filtering patients out of the nation's emergency departments when they need to be treated the most. The national study -- published in this month's American Emergency Medicine -- documents four cases in which a health maintenance organization's failure to cover emergency care resulted in life-threatening consequences for the patient. It suggests that a controversial HMO practice called "gatekeeping" might be to blame for these flawed decisions. Gatekeeping is the method many HMOs use to determine if a patient qualifies for emergency coverage. Under this system, when a patient arrives at an emergency department, the ED staff calls the patient's insurance representative, or "gatekeeper," to determine if the patient's HMO will cover the required treatment. But the gatekeeper does not always have medical training or expertise. The study found some dire results of this practice: Patients can be denied coverage even when their lives are in danger. "Telephone gatekeeping -- even by physicians -- did not reliably distinguish patients who could safely be denied ED care," said Sacred Heart emergency physician and study co-author Gary Young in a written statement. In several of the cases cited in the study, inadequate gatekeeping not only resulted in a lack of coverage, but also a lack of medical care. "In general, when patients are told that [they are not covered], they leave the ED," HUP emergency physician and study co-author Robert Lowe said. Lowe and Young decided to pursue the study because "we know how difficult it can be to assess how sick a person really is," said Lowe, who explained that he sometimes takes up to an hour to diagnose patients in the emergency room. "How can a person do that over the phone?" he asked. In the study, the doctors also present 21 cases in which an HMO's denial of emergency coverage would have caused the patients to leave unattended -- putting them at serious health risk -- had physicians not convinced them to seek emergency care. "We found some cases that were pretty concerning," Lowe said. "The bottom line is that the answer to our original question -- 'Does gatekeeping present a problem?' -- was yes." The study was published in the wake of President Bill Clinton's endorsement of the Consumer Bill of Rights and Responsibilities, a document which emphasizes "severe pain," among other symptoms, as sufficient qualification for patients to receive emergency coverage. So how can a gatekeeper in New York assess severe pain in Chicago? "Those sorts of ambiguities can create problems," Lowe said. To address those and other issues, he is now examining alternatives to gatekeeping as a means to reduce use of the emergency department. Lowe argued that if patients have "better access" to their doctors, they'll be less likely to end up in the ED.