PhotoWhen should someone go to the emergency room (ER) to seek treatment? It seems a simple question, but the answer appears to be in dispute in Minnesota, where the state health department and ER doctors don't see eye-to-eye.

It started when the Minnesota Department of Health (MDH) issued a report entitled Potentially Preventable Health Care Events in Minnesota. The report focuses on opportunities to reduce unnecessary healthcare spending, including for emergency care.

It's the latter category where the American CollegeofEmergencyPhysicians (ACEP) and Minnesota ACEP have taken issue.

Symptoms vs. final diagnosis

The report looks at ER visits and makes a judgment about whether or not they could have been avoided. But the standard by which they are judged is the final diagnosis, not the symptoms that brought the patient to the ER in the first place.

For example, a 56 year old woman suffers intense chest pain and goes to the ER because she thinks she may be having a heart attack. It turns out to be a really bad case of indigestion. Based on MDH's standard, this would classify as an avoidable healthcare event.

But the ER physicians group says this doesn't take into consideration the national "prudent layperson" standard, which says emergency visits must be covered by insurance companies based on patients' symptoms, not their final diagnoses. In fact, ACEP says this standard is included in the Affordable Care Act (ACA).


"It is very alarming that a report like this is being issued that directly undermines language in the ACA and patients' responsible use of the emergency department," said Dr. Michael Gerardi, president of ACEP. "Patients never should be forced into the position of self-diagnosing their medical condition out of fear of insurance not covering the visit. This applies 20/20 hindsight to possibly life-threatening conditions and it violates the national prudent layperson standard designed to protect patients' health plan coverage of emergency care."

Dr. Thomas E Wyatt, president of the Minnesota Chapter of ACEP, worries the report only serves to potentially scare patients away from the ER when they may need it most.

"Insurance companies historically have denied payment for emergency care based on patients' final diagnoses, not symptoms,” he said. “But symptoms are what determine whether visits are appropriate. Patients with chest pain should get immediate medical attention to determine whether or not they are having a heart attack. If the doctor discovers it was a panic attack, it was still right for that patient to seek immediate medical care, and his or her insurance should absolutely cover the visit."

The physicians say the MDH finding that a large number of ER visits should have been preventable, based on the final diagnosis, is at odds with other research on the subject. The groups say the latest national data on ER visits from the Centers for Disease Control and Prevention (CDC) found 96% of emergency patients needed medical care within two hours in 2011.

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