[Congressional Record Volume 141, Number 112 (Wednesday, July 12, 1995)]
[Extensions of Remarks]
[Pages E1417-E1419]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


    THE INTRODUCTION OF THE ACCESS TO EMERGENCY MEDICAL SERVICES ACT

                                 ______


                        HON. BENJAMIN L. CARDIN

                              of maryland

                    in the house of representatives

                         Tuesday, July 11, 1995
  Mr. CARDIN. Mr. Speaker, I rise today to introduce the Access to 
Emergency Medical Services Act. This legislation would end health 
plans' ability to deny coverage and payment 

[[Page E 1418]]
for appropriate emergency room visits. In addition, it would require 
health plans to pay emergency physicians and hospital emergency 
departments for federally required evaluation and screening exams.
  I'm sure most of you have heard stories from friends, relatives, or 
the press of people who received care in the emergency room, but their 
health plan refused to cover that care. Health plans are able to do 
this by claiming that the patient's diagnosis did not meet the health 
plan's definition of emergency. I have attached a recent New York Times 
article which highlights the problem.
  A 1992 study of Medicare's HMO claims denials conducted for the 
Health Care Financing Administration determined that emergency 
department visits were dispute prone. In fact, the study showed that 40 
percent of the claims denied by Medicare HMO's were for emergency care 
services. The study's author concluded that this was because HCFA's 
definition of emergency was regulatory and placed patients in the 
untenable position of having to make quasi-medical judgments about the 
severity of their symptoms. Unfortunately, for many patients, while 
their symptoms may suggest that they are experiencing a medical 
emergency, only a qualified health professional can ultimately make 
that determination after an appropriate medical evaluation.
  The State of Maryland has put an end to many of these after-the-fact 
denials by establishing a uniform definition of emergency that requires 
payment determinations to be based upon the patient's symptoms, rather 
than the patients ultimate diagnosis. Virginia and Arkansas have also 
adopted this definition. My legislation would take this prudent 
layperson definition of emergency and make it the national, uniform 
definition. In addition, the bill would do the following:
  Prohibit health plans from requiring prior authorization for 
emergency services or requiring that the health plan have a contractual 
arrangement with the hospital emergency department in order for care to 
be provided to the plan's enrollees.
  Require health plans to pay emergency physicians and hospital 
emergency departments for services they are required by Federal law to 
provide.
  Ensure 24-hour access and timely authorization--30 minutes--from 
health plans for needed care for an enrollee being treated in an 
emergency department.
  Assure that health plans promote the appropriate use of 911 emergency 
telephone numbers and do not create barriers to their appropriate use.
  Apply these same standards to Medicare and Medicaid.
  The Access to Emergency Medical Services Act is supported by both 
health care providers and consumer organizations. First, I would like 
to thank the American College of Emergency Physicians [ACEP] who have 
documented the need for this reform, and worked closely with me to 
develop this legislation. The bill is also supported by Consumers 
Union, the National Association of EMS Physicians, Citizen Action, the 
Coalition for American Trauma Care, Public Citizen, the American 
Ambulance Association, the International Association of Firefighters, 
and the Emergency Medical Services Section of the International 
Association of Fire Chiefs.
  The Access to Emergency Medical Services Act enables those in need to 
be assured of access to emergency medical care. This legislation 
provides a reasonable definition that may be applied to emergency 
situations, and safeguards patients both medically and financially. It 
is imperative that this Congress join in bipartisan support on this 
issue.
  Access to emergency medical service is fundamental to ensuring a 
viable health care system. What is at stake here is not an issue of 
governmental regulation, but an issue of protecting patient safety. I 
urge you, my colleagues, to join me in supporting the Emergency Medical 
Services Act.
                [From the New York Times, July 9, 1995]

  H.M.O.'s Refusing Emergency Claims, Hospitals Assert--2 Missions in 
                                Conflict


     managed care groups insist they must limit costs--doctors are 
                               frustrated

                            (By Robert Pear)

       Washington.--As enrollment in health maintenance 
     organizations soars, hospitals across the country report that 
     H.M.O.'s are increasingly denying claims for care provided in 
     hospital emergency rooms.
       Such denials create obstacles to emergency care for H.M.O. 
     patients and can leave them responsible for thousands of 
     dollars in medical bills. The denials also frustrate 
     emergency room doctors, who say the H.M.O. practices 
     discourage patients from seeking urgently needed care. But 
     for their part, H.M.O.'s say their costs would run out of 
     control if they allowed patients unlimited access to hospital 
     emergency rooms.
       How H.M.O.'s handle medical emergencies is an issue of 
     immense importance, given recent trends. Enrollment in 
     H.M.O.' doubled in the last eight years, to 51 million in 
     1994, partly because employers encouraged their use as a way 
     to help control costs.
       In addition, Republicans and many Democrats in Congress say 
     they want to increase the use of H.M.O.'s because they 
     believe that such prepaid health plans will slow the growth 
     of Medicare and Medicaid, the programs for the elderly and 
     the poor, which serve 73 million people at a Federal cost of 
     $267 billion this year.
       Under Federal law, a hospital must provide ``an appropriate 
     medical screening examination'' to any patient who requests 
     care in its emergency room. The hospital must also provide 
     any treatment needed to stabilize the patient's condition.
       Dr. Tom A. Mitchell, director of emergency care at Tampa 
     General Hospital in Florida, said: ``I am obligated to 
     provide the care, but the H.M.O. is not obligated to pay for 
     it. This is a new type of cost-shifting, a way for H.M.O.'s 
     to shift costs to patients, physicians and hospitals.''
       Most H.M.O.'s promise to cover emergency medical services, 
     but there is no standard definition of the term. H.M.O.'s can 
     define it narrowly and typically reserve the right to deny 
     payment if they conclude, in retrospect, that the conditions 
     treated were not emergencies. Hospitals say H.M.O.'s often 
     refuse to pay for their members in such cases, even if H.M.O. 
     doctors sent the patients to the hospital emergency rooms. 
     Hospitals then often seek payment from the patient.
       Dr. Stephen G. Lynn, director of emergency medicine at St. 
     Luke's-Roosevelt Hospital Center in Manhattan, said: ``We are 
     getting more and more refusals by H.M.O.'s to pay for care in 
     the emergency room. The problem is increasing as managed care 
     becomes a more important source of reimbursement. Managed 
     care is relatively new in New York City, but it's growing 
     rapidly.''
       H.M.O.'s emphasize regular
        preventive care, supervised by a doctor who coordinates 
     all the medical services that a patient may need. The 
     organizations try to reduce costs by redirecting patients 
     from hospitals to less expensive sites like clinics and 
     doctors' offices.
       The disputes over specific cases reflect a larger clash of 
     missions and cultures. An H.M.O. is the ultimate form of 
     ``managed care,'' but emergencies are, by their very nature, 
     unexpected and therefore difficult to manage. Doctors in 
     H.M.O.'s carefully weigh the need for expensive tests or 
     treatments, but in an emergency room, doctors tend to do 
     whatever they can to meet the patient's immediate needs.
       Each H.M.O. seems to have its own way of handling 
     emergencies. Large plans like Kaiser Permanente provide a 
     full range of emergency services around the clock at their 
     own clinics and hospitals. Some H.M.O.'s have nurses to 
     advise patients over the telephone. Some H.M.O. doctors take 
     phone calls from patients at night. Some leave messages on 
     phone answering machines, telling patients to go to hospital 
     emergency rooms if they cannot wait for the doctor's offices 
     to reopen.
       At the United Healthcare Corporation, which runs 21 
     H.M.O.'s serving 3.9 million people, ``It's up to the 
     physician to decide how to provide 24-hour coverage,'' said 
     Dr. Lee N. Newcomer, chief medical officer of the 
     Minneapolis-based company.
       George C. Halvorson, chairman of the Group Health 
     Association of America, a trade group for H.M.O.'s, said he 
     was not aware of any problems with emergency care. ``This is 
     totally alien to me,'' said Mr. Halvorson, who is also 
     president of Health-Partners, an H.M.O. in Minneapolis. 
     Donald B. White, a spokesman for the association, said, ``We 
     just don't have data on emergency services and how they're 
     handled by different H.M.O.'s.''
       About 3.4 million of the nation's 37 million Medicare 
     beneficiaries are in H.M.O.'s. Dr. Rodney C. Armstead, 
     director of managed care at the Department of Health and 
     Human Services, said the Government had received many 
     complaints about access to emergency services in such plans. 
     He recently sent letters to the 164 H.M.O's with Medicare 
     contracts, reminding them of their obligation to provide 
     emergency care.
       Alan G. Raymond, vice president of the Harvard Community 
     Health Plan, based in Brookline, Mass., said, ``Employers are 
     putting pressure on H.M.O.'s to reduce inappropriate use of 
     emergency services because such care is costly and episodic 
     and does not fit well with the coordinated care that H.M.O.'s 
     try to provide.''
       Dr. Charlotte S. Yeh, chief of emergency medicine at the 
     New England Medical Center, a teaching hospital in Boston, 
     said: ``H.M.O.'s are excellent at preventive care, regular 
     routine care. But they have not been able to cope with the 
     very unpredictable, unscheduled nature of emergency care. 
     They often insist that their members get approval before 
     going to a hospital emergency department. Getting prior 
     authorization may delay care.
       ``In some ways, it's less frustrating for us to take care 
     of homeless people than H.M.O. members. At least, we can do 
     what we think is right for them, as opposed to trying to 
     convince an H.M.O. over the phone of what's the right thing 
     to do.''
       Dr. Gary P. Young, chairman of the emergency department at 
     Highland Hospital in Oakland, Calif., said H.M.O.'s often 
     directed emergency
      room doctors to release patients or transfer them to other 
     hospitals before it was safe to do so. ``This is happening 
     every day,'' he said.
       The PruCare H.M.O. in the Dallas-Fort Worth area, run by 
     the Prudential Insurance Company of America, promises ``rock 
     solid 

[[Page E 1419]]
     health coverage,'' but the fine print of its members' handbook says, 
     ``Failure to contact the primary care physician prior to 
     emergency treatment may result in a denial of payment.''
       Typically, in an H.M.O., a family doctor or an internist 
     managing a patient's care serves as ``gatekeeper,'' 
     authorizing the use of specialists like cardiologists and 
     orthopedic surgeons. The H.M.O.'s send large numbers of 
     patients to selected doctors and hospitals; in return, they 
     receive discounts on fees. But emergencies are not limited to 
     times and places convenient to an H.M.O.'s list of doctors 
     and hospitals.
       H.M.O.'s say they charge lower premiums than traditional 
     insurance companies because they are more efficient. But 
     emergency room doctors say that many H.M.O.'s skimp on 
     specialty care and rely on hospital emergency rooms to 
     provide such services, especially at night and on weekends.
       Dr. David S. Davis, who works in the emergency department 
     at North Arundel Hospital in Glen Burnie, Md., said: 
     ``H.M.O.'s don't have to sign up enough doctors as long as 
     they have the emergency room as a safety net. The emergency 
     room is a backup for the H.M.O. in all it's operations.'' 
     Under Maryland law, he noted, an H.M.O. must have a system to 
     provide members with access to doctors at all hours, but it 
     can meet this obligation by sending patients to hospital 
     emergency rooms.
       To illustrate the problem, doctors offer this example: A 
     57-year-old man wakes up in the middle of the night with 
     chest pains. A hospital affiliated with his H.M.O. is 50 
     minutes away, so he goes instead to a hospital just 10 blocks 
     from his home. An emergency room doctor orders several common 
     but expensive tests to determine if a heart attack has 
     occurred.
       The essence of the emergency physician's art is the ability 
     to identify the cause of such symptoms in a patient whom the 
     doctor has never seen. The cause could be a heart attack. But 
     it could also be indigestion, heartburn, stomach ulcers, 
     anxiety, a panic attack, a pulled muscle or any of a number 
     of other conditions.
       If the diagnostic examination and tests had not been 
     performed, the hospital and the emergency room doctors could 
     have been cited for violating Federal law.
       But in such situations, H.M.O.'s often refuse to pay the 
     hospital, on the ground that the hospital had no contract 
     with the H.M.O., the chest pain did not threaten the 
     patient's life or the patient did not get authorization to 
     use a hospital outside the H.M.O. network.
       Representative Benjamin L. Cardin, Democrat of Maryland, 
     said he would soon introduce a bill to help solve these 
     problems. The bill would require H.M.O.'s to pay for 
     emergency medical services and would establish a uniform 
     definition of emergency based on the judgment of ``a prudent 
     lay person.'' The bill would prohibit H.M.O.'s from requiring 
     prior authorization for emergency services. A health plan 
     could be fined $10,000 for each violation and $1 million for 
     a pattern of repeated violations.
       The American College of Emergency Physicians, which 
     represents more than 15,000 doctors, has been urging Congress 
     to adopt such changes and supports the legislation.
       When H.M.O.'s deny claims filed on behalf of Medicare 
     beneficiaries, the patients have a right to appeal. The 
     appeals are heard by a private consulting concern, the 
     Network Design Group of Pittsford, N.Y., which acts as agent 
     for the Government. The appeals total 300 to 400 a month, and 
     David A. Richardson, president of the company, said that a 
     surprisingly large proportion--about half of all Medicare 
     appeals--involved disagreements over emergencies or other 
     urgent medical problems.
     

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