Congress Adopts Prudent Layperson Standard for Medicare/Medicaid Enrollees

Leaders in emergency medicine are hopeful standard will soon apply to all health plans

The inclusion of the "prudent layperson" definition of an emergency in the recent Budget Reconciliation Bill for Medicare and Medicaid beneficiaries enrolled in HMOs has many emergency medicine leaders hopeful that the standard will soon be applied to all health plans, possibly with the passage of the long-debated Access to Emergency Services Act.

"I think this significantly increase the momentum and chances for passage, now that [Congress] has covered these patients," says Larry Bedard, MD, FACEP, immediate past president of the American College of Emergency Physicians (ACEP), which has lobbied extensively for the standard’s federal adoption. "I can’t imagine how, since they have mandated it for Medicaid and Medicare patients, they would not extend it to the rest of us."

As part of a budget agreement bill for Medicare patients enrolled in HMOs, members of Congress attached several managed care consumer protection measures that included mandatory use of the "prudent layperson" definition; that version of the bill was passed last month.

Adoption of the standard means that a health plan must cover services delivered in an emergency department if the patient presents there with symptoms that a "prudent layperson," possessing an average knowledge of health and medicine, could reasonably expect to result in serious impairment to his or her health.

What it essentially means, says Bedard, is that health plans will be required to pay for emergency care based upon a patient’s presenting symptoms and not on the eventual diagnosis. The Medicare legislation further prohibits plans from requiring, as a condition of coverage, that patients obtain prior authorization from the plans before seeking emergency care.

The legislation is particularly noteworthy in that it guarantees that there will be no break in access to emergency care for a particularly vulnerable population, says Charlotte Yeh, MD, FACEP, Chief of Emergency Medicine at New England Medical Center in Boston, and chair of the government affairs section for ACEP.

"As we know, the Medicare population tends to use the emergency department appropriately in the first place," says Yeh. "This is to ensure that they will continue to have access, especially because they tend to be sicker and frailer."

Because the legislation mandates a specific approach for a large number of payers, Yeh says she is encouraged that this will "level the playing field" for payers and providers by ensuring they will at least start on the on the same page when it comes to determining what kinds of complaints will be seen in the ED.

"I am very pleased they are moving in this direction. Hopefully, it will lead to better coordination and collaboration between emergency services and managed care," she says.

Yeh agreed that passage of the "prudent layperson" standard for Medicare and Medicaid beneficiaries may provide the impetus needed to win passage of broader legislation later.

"I think there is recognition that this is one arena that is important to the American public," she explains. "It is one topic with broad bipartisan support compared to many of the other managed care issues. Unlike many of the other pieces of legislation, this doesn’t really fall into the area of micro-management (of the health plans)."

Bedard was also encouraged that the Medicare legislation included the language using "severe pain" in the definition of an emergency despite opposition from the HMO industry.

In a statement released shortly after the bill’s passage, Bedard explained the importance of the inclusion of the language in the "prudent layperson" standard.

"This measure is a significant victory for senior citizens, who have the highest rate of visits to the emergency department," he stated. "The symptom of severe abdominal pain may be caused by acute indigestion, a gall bladder infection, or a life-threatening aneurysm, so it is vital that the medically necessary tests be performed to determine the seriousness of these conditions."

Meanwhile, the College continues to press for passage of the Access to Emergency Services Act, lobbying representatives and senators to co-sponsor the bill and demonstrating support for those who were instrumental in putting together the current legislation.

During the month of August, ACEP sponsored visits by 20-30 legislators to local emergency departments to thank them for their support of the Medicare package.

"We don’t know if [Access to Emergency Services] will be voted on this year, there is a chance it won’t get passed," says Bedard. "Our goal by out Scientific Assembly in October is to get up to 200 co-sponsors."