HMOs oppose ‘prudent layperson’ standard

Lobbyists for the managed care industry are fighting bills under consideration in Congress that would force health maintenance organizations (HMOs) to pay for patients who report severe pain in hospital emergency departments (EDs). The bills are intended to protect consumers who go to EDs without prior approval from their insurers, and Congressional leaders have proposed a "prudent layperson" standard that would mean severe pain would qualify as a symptom of an emergency medical condition.

The American Association of Health Plans (AAHP) has released a list of complaints it forwarded to members of Congress, arguing that pain is a highly subjective term. Using the prudent layperson’s definitions of severe pain and emergency medical conditions, the AAHP argues, would result in overuse of EDs and possibly poor medical care; HMO payments would encourage overuse and lead to medication errors and misdiagnoses because ED physicians are unfamiliar with the patients. The standard also would greatly increase hospitals’ costs because emergency care is far more expensive than more appropriate care, the AAHP argues.