The clear-cut definition of what constitutes an emergency is blurring for HMO members who are increasingly confused about how to react in crisis situations when split-second decisions can mean life or death. Health plan communication on how members should handle emergencies is woefully inadequate, according to public safety educators.
Though Medicaid and Medicare health plans are federally required to cover emergency care, public confusion persists over the need for prior HMO approval and the potential for denied coverage in situations ultimately diagnosed as non-emergencies. Widely held fears about managed care organizations wielding too much control over emergency care were recently spotlighted in a front-page USA Today story (Aug. 24) that characterized Kaiser Permanente as an "overseer" of emergency services in certain markets.
The headline "Who do you call: 911 or your HMO?" poses the disturbing question that health plan members struggle with and HMOs have sent mixed messages about. A recent study by Oregon Health Sciences University in Portland found that HMO ER rules vary widely and can be ambiguous and sometimes misleading. For instance, nine of the 15 plans evaluated asked members to distinguish between an "emergency and urgent condition." And though most of the health plans' literature advised members to call 911 in an emergency or go to an emergency department, four of them failed to mention this directive.
Responding to Non-emergencies
The USA Today article profiled Kaiser's new and controversial $600 million contract with American Medical Response (AMR), a medical transport company that will provide transportation services for Kaiser members. Although the program was developed to better respond to non-emergency situations and as a backup to Kaiser's health advice services, the concern is that members may perceive it as a 911 replacement - a fear emphasized in the article. The service has direct access to local 911 ambulance systems. Critics accuse the program of undermining multiple years of public education that promoted 911 as the only appropriate emergency response.
Kaiser dropped the ball on effectively communicating its relationship with AMR, admits Laura Marshall, who works in Kaiser's national media relations office. She says that the service was never designed to replace 911. It's ironic that Kaiser is catching so much heat on its emergency policy. It was one of the leading health plans that helped draft the prudent layperson federal legislation, included in the 1997 Balanced Budget Act, that required managed care organizations to cover emergency care.
Marshall says that since the USA Today article ran, Kaiser has been in clarification mode, reminding members of what emergency symptoms are and the importance of 911 in those instances via member newsletters and nurse advice lines. Kaiser also is looking at including a uniform 911 message on all of its member cards.
The bigger, more costly issue of preventing non-emergency cases from being cared for by emergency care workers is what Kaiser is trying to address with its AMR contract, says Marshall. Humana and Foundation health plans also are test-driving AMR programs in south Florida. Health plans often claim that the emergency care system is overburdened with non-emergency cases. But these abuses are exaggerated by health plans and are most prevalent within the homeless and uninsured populations, says MaryJane Fingland, director of public relations for the American College of Physicians (ACEP). The controversy Kaiser's plan triggered should serve as a wakeup call to other health plans that their emergency policies need to be clearly spelled out and uniform, says Fingland.
Dr. Don Young, COO and Medicare director of the Health Insurance Association of America (HIAA), agrees that health plans have been too ambiguous on the issue of emergency care and need to become more proactive about educating members. He suggests providing daily reminders of what emergency symptoms are and examples of non-emergencies via member newsletters and the media.
(Kaiser, Laura Marshall, 510/271-5826; ACEP, Mary Jane Fingland, 202/728-0610, ext. 3007; HIAA, Dr. Don Young, 202/824-1787)
Rescuing 911
For many HMO members confronted with an emergency medical condition, the knee-jerk reaction is not to call 911 but to call their HMO. Emergency health workers, worried that 911 public safety efforts are being undermined, are calling for managed care plans to:
- develop uniform emergency guidelines;
- educate members repeatedly on emergency symptoms; and
- incorporating the prudent layperson's standard of emergeny in all HMO policies.