![]() ![]() Recently, Anthem, Inc, a large national health insurance company that provides coverage for 1 in 8 Americans, 8 instituted a policy that will deny coverage and payments for ED visits that it deems unnecessary. Because patients make care-seeking decisions based on their symptoms, using a diagnosis-based approach to retrospectively identify inappropriate visits as means of determining coverage may be problematic. Their findings indicated that there is no clear link between many presenting symptoms and discharge diagnoses considered primary care–treatable. This diagnosis-based approach has not been well studied, but an analysis by Raven et al 7 using the Billings algorithm demonstrated that nearly 90% of US ED visits had the same presenting symptoms as the ED visits with diagnoses considered primary care–treatable. These ED visits are often labeled as inappropriate or nonemergent using definitions based on ED discharge diagnoses, 4, 5, 6 which are readily available in insurance billing claims. One tactic is to apply financial disincentives, such as coverage denial, to ED visits that could presumably be cared for in alternative settings, such as a physician’s office, urgent care center, or retail clinic. 1, 2, 3 This growth has compelled public and commercial payers to pursue strategies to reduce ED care use. She did not receive compensation for her contribution.Įmergency department (ED) visits and payment for ED visits by insurers and patients have grown substantially in the United States over the past several decades. ![]() No other disclosures were reported.Īdditional Contributions: Arah Schuur, MA, provided feedback on the manuscript. Dr Schuur reports grants from American College of Emergency Physicians and grants and personal fees from the Emergency Medicine Foundation outside the submitted work and also serves as a committee member of the American College of Emergency Physicians on the Quality and Patient Safety Committee. Corresponding Author: Shih-Chuan Chou, MD, MPH, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 ( Contributions: Dr Chou had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Ĭoncept and design: Chou, Baker, Venkatesh, Schuur.Īcquisition, analysis, or interpretation of data: Chou, Gondi, Venkatesh, Schuur.Ĭritical revision of the manuscript for important intellectual content: Chou, Baker, Venkatesh, Schuur.Īdministrative, technical, or material support: Schuur.Ĭonflict of Interest Disclosures: Dr Venkatesh reports career development support (grant KL2TR001862) from the National Center for Advancing Translational Science and the Yale Center for Clinical Investigation.
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