Can you ignore the gatekeeper? One study indicates you should

Study finds evidence of poorer outcomes when gatekeepers denied coverage of treatment in the ED

Can you afford to lose $400 per patient? A small but growing cadre of hospitals nationwide are willing to risk millions to prove a point: Those irksome preauthorization protocols, which require telephoning a patient's insurer for coverage, are actually unnecessary.

In fact, you can disregard them most of the time without jeopardizing payments, observes Gary P. Young, MD, director of the ED at Sacred Heart Medical Center in Eugene, OR.

"There's no law that says you have to make those calls," Young says.

If the attending physician knows how to properly treat a patient, there should be no question about a claim getting paid, Young adds. In the early 1990s, Sacred Heart officials informed payers that it would stop making insurance preauthorization calls. Despite the change, the provider has had few problems getting paid, Young states.

Hospitals are ignoring payers

Even bills that are initially rejected due to questions, which happens less than 10% of the time, eventually get paid when they're resubmitted. "It's really not a big deal," Young says.

In August, directors at Phoenix, AZ-based Samaritan Health System implemented a "no triage out" policy for it's four Phoenix-area hospitals. Concerned about possible patient-dumping law violations, emergency physicians have begun to ignore the recommendations of insurers when told to redirect certain patients to an urgent or primary care facility.

Instead, they routinely provide all the medical screening and "necessary procedures to reasonably rule out an unstable medical condition," according to Todd B. Taylor, MD, a member of the group. Rebellion isn't the issue here, says Young. There's a growing sense among emergency physicians and administrators that preauthorization calls, while potentially limiting excessive utilization, can actually harm some patients.

Critics of managed care gatekeeping have long cited flaws with the system. How can anyone, they say, even a medical doctor, accurately assess what is good for a patient over the telephone? Only an on-site physician can make these judgment calls, they contend. The concern has been echoed for years in studies and journal editorials.

System victimizes non-urgent patients

But the system seems to prevail, partly because we let it, says Robert A. Lowe, MD, MPH, assistant professor of emergency medicine and epidemiology at the University of Pennsylvania School of Medicine in Philadelphia.

"The issue really turns on how to reliably differentiate between urgent and non-urgent cases. Many of these patients present with serious underlying disorders," such as bacterial meningitis, that are often masked by other symptoms, Lowe says.

MCOs believe they can intelligently redirect these patients to less expensive sources of medical care based on presenting factors, Lowe adds. But the matter isn't so simple, he says.

Some 80% of ED visits turn out to be non-urgent and cost the health care system an average of $400 per visit. Simple sore throats and ankle sprains fall into this category, Lowe says.

But a great many of these cases, as many as half according to Young, end up receiving either poor follow-up care or none at all when gatekeepers deny coverage for the emergency visit.

While the hospital doesn't officially deny treatment, patients who can't afford to self-pay often refuse services. But they don't often go on to a primary care physician as directed by the gatekeeper either, he adds.

Developments such as the prudent layperson standard and the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 are supposed to address these issues. (See related story on page 17.) But these safeguards, while well-intentioned, don't cover patients who refuse medical care because they can't afford it, says Young.

One bad outcome is too many

The actual number of these patients is probably quite small. But "if one out of 200 patients who were denied coverage had an adverse outcome due to a coverage denial, that would be one too many," Lowe says. The sad reality, he adds, is that hospitals can't provide free care to everyone who presents with a medical problem. Someone has to pay the bill.

The problem isn't with EMTALA or prudent layperson, according to many physicians. The gatekeeping process interferes with clinical judgment by introducing financial considerations into direct patient care, they complain.

Now there is evidence that gatekeeping may actually increase the potential for adverse outcomes in patients denied coverage. A survey of 143 patients conducted by Young and Lowe in 1996 found a significant number of incidents involving adverse outcomes linked to coverage denials in the ED.1

"The limited studies that have looked at outcomes of patients redirected away from EDs after a limited triage evaluation raise questions about the safety of this approach," Young and Lowe write in their study.

The survey found that more than 25% of the patients in which payment in the ED was denied suffered either adverse outcomes or were placed at increased medical risk by gatekeepers' decisions.

But the more startling finding was that 72% of the cases were defined by Young and Lowe as "near misses." These were patients who received treatment in the ED despite the gatekeepers' denials. Their medical conditions, it turned out, were far worse than believed based on symptoms initially reported to the gatekeepers.

One example involved a 75-year-old female who presented with severe lower abdominal pain. The MCO's physician only authorized an oral analgesic. The ED staff provided more extensive treatment. The patient was ultimately diagnosed with a bowel obstruction.

Excesses led to gatekeeping

An earlier study of pediatric outcomes found that 40% of the time, the children failed to receive adequate primary care follow-up when the MCO denied coverage.2

Young and Lowe acknowledge that the link between coverage denials and adverse outcomes is inconclusive based on their survey. More extensive research is needed. The survey doesn't try to suggest that all MCOs are bad either, Lowe points out.

But neither is the purpose behind preauthorization, says Peter Franks, MD, a primary care physician at the University of Rochester in New York who defends some forms of preauthorization.

The tendency for excessive clinical testing and overprescribing are not in a patient's best interest, Frank says. There are adverse outcomes associated with over-prescribing too, he adds.

"Over the past two decades in the United States there has been a trend toward increasing intensity of care," helped by advancements in technology, Franks observes. Primary care physicians were once gatekeepers of the health care system. "We need to reclaim the gatekeeper concept," and protect patients from the detrimental effects of unnecessary medical services," he concludes.

Look before leaping

Before revising your hospital's policy on preauthorization compliance, you may want to consider a dissenting viewpoint on the subject. Thomas Mayer, MD, MBA, an independent managed care consultant in Huntington Beach, CA advises caution. Simply ignoring the managed care organization (MCO) on preauthorization is impractical, Mayer says, even if the MCO initially agrees to go along with the idea. The health care system has become far too complex and competitive to simply disregard payment protocols.

"A payer today is likely to be a risk-bearing entity owned by the medical center across the street. You could lose the business if you're not careful," Mayer says.

Preauthorization has a place in acute-care settings, Mayer adds. It creates accountability in a managed care system. At one time, the role belonged to the primary care physician. In many instances, it still does.

Ultimately, the solution lies in having emergency physicians assume risk for their patients. It eliminates the need for payment approvals and gives providers a personal stake in clinical outcomes.

But the risk has to be global, Mayer says. "You can't capitate the emergency physician downstairs and carve out the cardiologist upstairs, or the system will discriminate against heart patients in the emergency setting," Mayer says. There will be no incentive for emergency providers to be responsible for the heart patient.



    1. Young GP, Lowe RA. Adverse outcomes of managed care gatekeeping. Acad Emerg Med 1997;4:1129-1136.

    2. Shaw KN, Selbst SM, et al. Indigent children who are denied care in the emergency department. Ann Emerg Med 1990;19:59-62.