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Adverse Outcomes of Managed Care Gatekeeping, Young, Lowe

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Adverse Outcomes of Managed Care Gatekeeping Gary P: Young, M D , Robert A . Lowe, M D , M P H

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ABSTRACT

Objectives: To determine whether telephone preauthorization for reimbursement of ED care (medical “gatekeeping”) by managed care organizations (MCOs) is associated with adverse outcomes. Methods: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3 ) “near miss” (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. Results: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy ( n = 21, pneumothorax ( n = 2). alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococcal meningitis in immunocompromised host, endocarditis, incarcerated inguinal hernia, meningococcemia, meningococcal meningitis, peritonsillar abscess, pneurnococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina. Conclusion: Adverse outcomes occur with MCO gatekeeping. Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study. Key words: managed care; adverse outcome; gatekeeping; clinical practice; emergency department; emergency medical services. Acad. Emerg. Med. 1997; 4:1 129- 1136

From the Sacred Heart Medical Center, Eugene. OR, Emergency Department (GPY): Highland Hospital, Alameda County Medical Center, Oakland, CA, and Universiry of California at San Francisco, Sat1 Francisco, CA f GPY): and University of Pennsylvania Medical Center, Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics. Philadelphia, PA, Departments of Emergency Medicine and Biostatistics and Epidemiology (RAL).

Received: January 15, 1997; revision received: May 12, 1997; accepted: May 14, 1997: updated: M a y 27, 1997. Prior presentation: American College of Emergencv Physicians Scientific Assembly, Washington, DC, September 1995. Young, MD, EmerAddress for correspondence and reprints: Gary gency Department, Sacred Heart Medical Center, I255 Hilyard Street, Eugene. OR 97401. Fax: 541 -686-3767: e-mail: [email protected]

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I Nearly 100 million ED visits occur annually in the United States, consuming 3% of the U.S. health care budget.’ There is considerable controversy as to what proportion of ED visits are nonurgent. Reports of the proportion of ED visits that are “appropriate”2-’6 have ranged from 18%12 to 89%.3The lower rates of appropriateness are often determined by retrospective chart review, rather than prospective clinical evaluation. Nonetheless, some have argued that if nonurgent patients could be redirected to traditional primary care settings, substantial reductions in charges for ED care might result.” However, there is information regarding the safety of refusing care to patients seeking care i n the ED based on payment authorization telephone calls to managed care organization (MC‘O) personnel (medical “gatekeepers”). 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 Despite this legal and clinical risk, many MCOs consider “ED gatekeeping” to be a cost-containment measure. When enrolled members of some MCOs present to EDs, unless these patients have medical problems that clearly pose immediate life threats, ED personnel are asked to contact a primary care physician (PCP) affiliated with the patient’s MCO for authorization before seeing the patient. As described in Appendix A, the mechanism of implementation of ED gatekeeping varies among MCOs and among EDs. The assumption that PCPs can determine by telephone the safety of deferring care remains unproven. Two published studies looking at outcomes of pediatric patients denied authorization for ED visits through MCO gatekeeping mechanisms both raised concerns about its as did another study analyzing the outcomes of patients who sought care from a general hospital ED.’9 The purpose of this study was to solicit and systematically review case reports of possible adverse outcomes occurring after ED gatekeeping, in order to ascertain whether any such adverse outcomes occurred and to determine what sorts of problems might be expected under MCO gatekeeping. It was recognized from the outset that such a collection of case reports would not provide information about the frequency of adverse outcomes under MCO gatekeeping, nor would it demonstrate that gatekeeping was less safe than other alternatives. Nevertheless, in view of the limited information available about the safety of the practice, this structured analysis should provide useful preliminary information to guide future investigations.

I METHODS Study Design: A structured review using a solicited case series from U.S. EDs was performed to identify possible adverse clinical outcomes in association with MCO

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gatekeeper denial of payment for ED care. The study was approved by the Institutional Review Board of the University of Pennsylvania. Population: Case reports were solicited from 4 different sources: 1) members of the California chapter of the American College of Emergency Physicians (ACEP); 2 ) national ACEP members; 3) members of SAEM; and 4) subscribers to an Internet emergency medicine (EM) discussion list. Case reports were solicited via newsletters and over the Internet. The general MCO gatekeeping process is outlined in Appendix A. Inclusion criteria for the present study required ED personnel (clinical or nonclinical staff) to have telephoned the MCO’s on-call gatekeeper (clinical or nonclinical MCO personnel) requesting preauthorization to receive reimbursement for the provision of medical care in the ED, and the gatekeeper’s response had to b e a denial. Even if the gatekeeper’s initial decision was subsequently reversed (e.g., due to subsequent intervention by the emergency physician), the case was considered eligible for inclusion. Excluded cases were primarily reports of interactions with the MCOs that occurred after the patient was seen by the emergency physician. Finally, when insufficient information was available, the case was excluded. Measurements: The respondents were asked to supply the following information: patient demographic information; chief complaint; details of the gatekeeping interaction; disposition; and follow-up information (Appendix B). In some cases, reporting physicians included copies of the ED medical record. Due to the requirement for patient confidentiality and the use of a report form with specific data entry points, actual medical records were reviewed in only a small minority of cases. Reported case material was reviewed independently by the authors (both EM residency-trained, board-certified emergency physicians) to assess eligibility for inclusion. Eligible case reports were classified into 1 of 4 categories, based on the authors’ judgment, to reflect events after gatekeeper denial of emergency care: 1 ) preventable morbidity or mortality as a direct result of the denial of ED care; 2) patients who were placed at increased risk of death or disability due to the gatekeeping interaction, but for whom no adverse outcome occurred; 3) “near misses,” patients for whom the subsequent intervention of ED personnel prevented adverse outcomes or suffering by providing needed care despite initial gatekeeper denial of authorization for ED care; and 4) none of the above. In order to enhance validity of the classifications, both authors independently reviewed all eligible cases and resolved any discrepancies in classification. When insufficient information was available or reports could not be confirmed, the case was excluded.

Adverse Outcomes of Managed Care Gatekeeping, Young, Lovtie

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A total of 133 case reports were received during 1993 and 1995. Most of the 114 excluded reports described disagreements between emergency physicians and gatekeepers occurring afrer the emergency physician examined the patient or represented MCO retrospective denials of payment for ED care. Of the 29 reports (20%) that satisfied case definition criteria, there were 4 (14%) patients with adverse outcomes, 4 ( 13%) patients placed at increased risk, and 21 (72%) near miss cases. All of the cases came from different EDs, representing 9 different states (CA, FL, GA, NM, NY, OK, OR, PA, TX), with the majority from California. Adverse garekeeying outcoines involving pre\,entahle morbidity or mortality included the following: 1. A 2-year-old female with fever presented to an ED where she was seen by a triage nurse but not by an emergency physician. Her parents were told over the phone by the MCO gatekeeper that their daughter needed to go to another ED at an MCO plan facility. She was seen 1 hour later at another hospital ED. Her diagnosis was fulminant meningococcemia. She required intubation and transfer by ambulance to the local children’s hospital for pediatric intensive care unit (ICU) admission. It was the policy at the first ED to have patients or parents call their MCO’s gatekeeper for payment authorization before being seen at that ED-or, as in this case, sent elsewhere. ED personnel never talked with the MCO personnel, and the MCO gatekeeper was unknown by the reporting physician. 2. A 22-year-old female with severe lower abdominal pain presented to an ED. Over the phone, the gatekeeper told the triage nurse that the patient was to go to the MCO plan’s ED by private automobile. The initial ED did not have a procedure for documenting MCO contacts, so the ED nurse did not make a record of the call with the gatekeeper; the patient did not speak with the gatekeeper. The ED nurse encouraged the patient to remain and receive care despite the patient’s concerns that the bill would not be paid. Despite these entreaties, the patient left, to travel by car to the other ED. During transport she had a syncopal episode. She arrived at the second ED hypotensive from a 2-L hemoperitoneum from a ruptured ectopic pregnancy. An ED chart was never made at the initial ED and the patient was never evaluated by a physician. 3. A 33-year-old female with vaginal bleeding arrived at the ED at 6 AM, but ED clerks were told by the MCO gatekeeper that the patient must wait until a gynecology clinic opened at 9 AM. At about 7 AM, she slumped over in the clinic waiting area, where she was found to be in hypovolemic shock by ED personnel responding to an overhead stat page. She developed asystolic arrest, from which she was resuscitated in the ED. She required an emergent hysterectomy for a large vascular fibroid. There

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was no documentation as to the identity of the gatekeeper, and apparently the ED clerks did not involve the local ED triage nurse. 4. A 29-year-old male with acute onset of abdominal pain presented to an ED at 4 AM. The physician gatekeeper denied authorization for care at this ED; instead, the patient was given an appointment to be seen at 1 PM the same day. The patient went home without a physician evaluation. At 8 AM on the same day, the patient returned to the ED because of increased pain. The physician gatekeeper again refused payment for care because the patient had an appointment to be seen that day in the MCO clinic. The patient again went home without a physician evaluation. At 11:30 AM on the saine day, the patient returned to the ED due to unbearable pain. The physician gatekeeper denied payment authorization for the third time that day. The patient then elected to be seen by an emergency physician at his own expense. By 12:30 PM, the patient was found to have free air under the diaphragm on radiographs. At 1:30 P M , 9.5 hours after initially presenting to the ED, the patient was taken to the operating room for an exploratory laparotomy and repair of his ruptured duodenal ulcer. The patient’s surgeons stated that the postoperative course was complicated and prolonged due to the delayed treatment. Patients placed at increased risk due to gatekeeper inter-actions included the folloir~iiig: 1. A 55-year-old male with a sore throat and fever was seen by a triage nurse at the first ED. The gatekeeper requested that the patient go to an MCO plan ED. On evaluation at the MCO plan’s ED, the patient was diagnosed as having epiglottitis and admitted to an ICU. 2. A 74-year-old female complained of pain in the back and both arms. The evaluation of the patient was performed by a triage nurse. The patient then gave registration information to an ED clerk, who called the oncall physician gatekeeper. The gatekeeping physician directed the clerk to send t h e patient to the office from the ED. The gatekeeping physician never spoke to the triage nurse. After the patient waited i n the office several hours, she was found to have an acute myocardial infarction (MI) on the office ECG. She w a s transferred back by ambulance to the hospital for direct admission to the cardiac care unit. 3. A 14-year-old female with severe abdominal pain presented to the ED triage with normal vital signs. The physician gatekeeper told t h e triage nurse to send the patient to the office. She was diagnosed as having a ruptured ectopic pregnancy and was transferred back to the hospital by ambulance for emergent laparotomy. 4. A 29-year-old female presented to an ED with hip pain and fever. She had a history of injection drug use. Her gatekeeper denied authorization for ED care; the patient left the ED partway through her evaluation because

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TABLE 1 Patients Provided E D Care Despite Managed Care Gatekeeping Authorization Denial (“Near Misses”) ................................................................................. ...................................................

Age (Years)

Sex

65 31 22

Male Female Female

2 71

Female Male

43

Female

22

Female

32

Female

22 35 1

Female Male Female Female Female Male Male Female Male

8 24 1 33 31 6

21

Female Male

58

Male

61

Male

75

DiagnosisKondition (Initial MCO* Gatekeeper Response) Abdominal aortic aneurysm presenting with flank pain (MCO physician directed nurse to send patient to the office) Alcohol withdrawal seizures and pancreatitis requiring intensive care (MCO physician denied authorization) Appendicitis with classic presentation at triage (MCO physician denied authorization, then required transfer to MCO hospital after diagnosis was made) Bacterial meningitis (ED clerk called MCO clerk, who referred patient to MCO plan’s hospital) Cerebrovascular accident (MCO gatekeeper denied authorization; MCO’s neurologist called in on the case after emergency physician diagnosis) Cryptococcal meningitis in immunocompressed host (MCO physician directed triage nurse to tell patient to go to the office the next day) Ectopic pregnancy with hemoperitoneum (patient had syncope when she stood up to leave the ED at the direction of the MCO staff) Ectopic pregnancy in patient with tuba1 ligation and positive pregnancy test (MCO physician directed patient to go to M C O clinic) Endocarditis in IV drug user (ED clerk called MCO physician’s office clerk, who directed patient to go to the office) Incarcerated inguinal hernia (ED clerk called MCO physician’s office; authorization denied) Meningococcemia (MCO physician denied authorization for ED visit related to fever and rash) Meningococcal meningitis (MCO physician denied authorization for ED visit; child living in shelter with mother) Peritonsillar abscess necessitating drainage then IV antibiotics in hospital (MCO physician denied authorization) Pneumococcal meningitis (MCO physician denied authorization for ED medical screening examination) Pneumothorax (ED clerk called M C O physician, who denied authorization because patient had used ambulance) Pneumothorax, 70% (ED staff called MCO physician, who requested that patient go to his office) Shock from gastrointestinal bleeding (MCO physician denied authorization because parents did not go to pediatrician’s office before going to the ED) Small bowel obstruction (MCO physician authorized oral analgesics only) Schizophrenia exacerbation necessitating psychiatric hospitalization (MCO physician denied authorization; psychiatrically unstable patient whose wife had to deceive him into coming to the ED) Suicidal depression necessitating psychiatric hospitalization (MCO staff directed patient to go to behavioral health resource) Unstable angina (MCO physician directed patient’s wife to drive him to MCO’s hospital)

*MCO = managed care organization

of concerns about paying for the ED bill. She was seen in the MCO clinic the next day and was treated with an NSAID. She was admitted 5 days later to the initial hospital for a septic hip. Although some might classify this case as a quality issue in the MCO clinic in which she was evaluated, the high likelihood that she had a septic hip at the time of her initial ED presentation led both authors to include her in this category.

Patients for whom ED care was provided despite initial gatekeeper denial of authorization for ED care: The 21 near-miss diagnoses are summarized in Table 1. In each of these cases, the MCO gatekeeper denied authorization for the ED visit but ED staff intervened and convinced the patient to receive care in the ED.

I . .DISCUSSION ..................... These cases raise questions about the assumption that MCO gatekeeping for ED visits is being practiced in a safe manner. Only 3 published studies have looked at outcomes of patients denied ED care; 2 of these were limited to ~ h i l d r e n . ’ One ~ . ~ study ~ . ~ ~found that 40% of the children never saw a physician in follow-up after MCO denial of payment for ED care, and those who did often received

treatment indicating that the patient warranted urgent care at the initial ED visit.’* In that study, 1% of the patients for whom the MCO refused authorization for payment were hospitalized, and for 3% of the patients who saw a PCP in follow-up, the PCP believed that the child should have been originally seen in the ED. Two critically ill children were initially denied ED care. Follow-up information was not available from 45% of the patients. Another pediatric ED study found that 43% of the children never saw a physician in follow-up and that l % of the children who were denied ED care were hospitalized.2s Of note, the EDs for both of these studies had a policy that attending emergency physicians briefly evaluate most children denied care before they left the ED. One might expect an even higher hospitalization rate in MCO authorization for payment refusal cases were such a policy not in place. Requiring a second examination before allowing patients to leave the ED is likely to improve the sensitivity of the screening process. There are data suggesting that physicians are more sensitive than nurses for predicting the need for hospitalization of ED patients based on triage information.26 The third study analyzed the outcomes of 545 patients who sought ED care but were denied authorization, 516 of whom chose to leave

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the ED.29The authors reported that 9 patients denied au- that blamed the COBRA violation on a MCO. The Health thorization for payment were sent back to the ED with Care Financing Administration (HCFA) serves as the fedsuch diagnoses as pulmonary embolus, MI, respiratory eral regulatory body for COBRA investigations. Gatekeeping practices currently represent the largest number failure, and sepsis. Data from the National Medical Care Utilization and of COBRA infractions investigated by HCFA (personal Expenditure Survey also hint at the magnitude of the communication, HCFA Regional Office, Seattle, WA, problem. In the 1980 survey, 43% of the ED visits were 1996). A recent article concluded that the first 8 years not considered likely to become serious. However, this (1986- 1994) of COBRA law resulted in few penalties.39 supposedly “nonurgent” group had a hospitalization rate However, in 1994, HCFA released clarifications of the of 5.8%, representing 18% of all hospital admissions COBRA rules and regulation^,^^ which have since resulted through the ED.30Although decisions made by ED triage in more investigations and penalties (personal communinurses who have the advantage of actually seeing the pa- cation, Judy Ramberg, HCFA Regional Office, Seattle, tient are not strictly comparable to decisions made by a WA, 1996). Along with literature cited a b o ~ e , ’ ~ . ’ ’the . ~ ~present PCP over the phone, reports of triage error rates also suggest the potential magnitude of gatekeeping errors. A 1994 study suggests that gatekeeping as currently practiced by survey involving 56 EDs nationally discovered that 5.5% telephone may be associated with adverse outcomes. Unof the patients initially triaged by nurses as “nonurgent” less larger studies demonstrate the safety of ED gatekeepwere subsequently admitted to the hospital during the 24- ing, our study suggests the clinical soundness of a polhour study, representing 13% of all hospital admissions icy that maintains compliance with COBRA regulations. through the ED.3’ Studies of patients triaged to nonemer- COBRA mandates that all patients seeking care in an ED gent sites of care by ED triage personnel report that 0.25% should be evaluated in person by a physician or other qualified staff (including specially trained nurses, if so deto 1.9% required hospital admission the same Other studies of ED triage nurse decision making com- fined in hospital bylaw^),^^-^' regardless of gatekeeping decisions made by MCO personnel over the telephone. pared with that of emergency physicians26.” or P C P S ~ ~ The present study suggests that a conventional triage evalshould also raise concern about the gatekeeping practice uation may not be sufficient to detect patients at risk of of relying on the telephone conversation between an ED adverse outcomes if denied ED care, and conventional triage nurse and the PCP to determine whether a patient triage evaluations do not meet the COBRA requirement is denied ED care. One study found poor agreement bethat nurses performing the medical screening examination tween nurses’ prospective and physicians’ retrospective must be specially triage categorizations; the physicians were more accurate, It is important to note that denial for payment by gatedetermining that more patients had urgent condition^.^' keepers does not mean that hospital personnel and emerAnother study using PCPs to treat patients triaged by gency physicians must deny care. On the contrary, ED nurses as having “primary care” problems found that personnel are bound by COBRA law to continue to pro10% of these “nonemergency” cases required hospitalivide for a screening evaluation and any indicated stabilizzation and 9% required emergency referraL3’ A study ing treatment, regardless of insurance status or initial decomparing ED nurses, emergency physicians, and PCPs found wide variation (from 11% to 63%) for the propor- nial of payment. However, it is equally clear that denial tion of ED visits considered urgent and poor agreement of payment for ED visits through MCO gatekeeping may between the prospective assessments of the triage nurses adversely affect patient decision making. The general puband the retrospective assessments of the reviewers.33An- lic deserves a better understanding of the risks that such other study examining ED triage assessment by nurses a practice may pose upon their choice to obtain emergency health care. compared with physicians found limited ability to predict which patients required admission; the nurses had a senI . .LIMITATIONS AND FUTURE QUESTIONS . . . .................... . . , . . ........................ sitivity of 41% in predicting admission, compared with 62% for the physicians.26 As a collection of case reports, this study is limited in Section 9121 of Public Law 99-272, the 1986 Con- several ways. Most important, this study neither detected solidated Omnibus Budget Reconciliation Act (COBRA), all adverse outcomes nor identified the number of patients mandates that hospital EDs provide appropriate screening denied authorization without subsequent problems. Thereto determine: “whether or not an emergency medical con- fore, these data cannot be used to determine the frequency dition . . . exists or to determine if the individual is in of adverse outcomes in patients whose PCPs deny auactive l a b ~ r . ” ’ ~ - ~With ’ respect to COBRA law, MCO thorization for ED visits. Nonetheless, the results of this gatekeeping places emergency physicians and their hos- study are disturbing and worthy of further investigation pitals in a legally awkward situation. There is no reason with large, prospective studies in general hospital EDs so to expect that emergency physicians or hospitals would that questions regarding the true frequency of adverse be released from liability for bad outcomes by a defense events after MCO gatekeeping can be answered.

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Another limitation of the study is selection bias. Only cases of gatekeeping with adverse outcomes were solicited. Respondents were not a random sample of emergency physicians, but rather physicians who had encountered adverse outcomes and were dissatisfied with the gatekeeping requirements of MCOs. No attempts were made to obtain a representative sample of denials from across the United States. Although most of the cases came from California, individual EDs were not represented more than once. Although the study suggests that “near misses” are more common than actual adverse outcomes, emergency physicians may be more likely to learn of and report near misses, in which the patient is eventually seen in the same ED despite MCO denial of payment, than they are to learn of actual adverse outcomes, which occur away from the ED. Furthermore, emergency physicians may be afraid to report adverse outcomes for fear of being implicated in potential COBRA violations or medicolegal actions, or for fear of MCO or hospital reprisals. Positive reinforcement for correcting the perceived errors of others also may have led emergency physicians to report more near misses. It is possible that the high proportion of near misses compared with adverse outcomes reported herein is due to these and other biases. The lack of independent chart review for verification of most reported cases is another important limitation of this study that may have affected the authors’ categorization of the selected cases. As noted above, the requirement for patient confidentiality and the use of a structured report form resulted in few medical records’ being made available for the authors to review. In those cases in which medical records were not obtained, the reporting physicians generally included sufficient detail in their reports to allow the 2 authors to classify the cases reliably. When insufficient information was available, the case was excluded. Several of the cases with preventable morbidity might arguably be classified as COBRA violations, placing the blame on the EDs rather than on MCO gatekeeping policy. Some readers might believe that patients as ill as these required more complete evaluations in the ED to qualify as medical screening examinations under COBRA, and that these patients should have been required to sign out against medical advice if they left the ED. However, not all EDs routinely require a physician to examine patients who are refused ED payment by their MCOs, nor do all EDs require that patients refused authorization for ED payment sign out against medical advice. It is beyond the scope of this paper to test whether emergency physicians, complying with the strictest interpretation of COBRA requirements, would be able to convert all category 1 cases (preventable morbidity or mortality) into category 3 (near misses). Instead, the article describes what actually occurred when practicing emergency physicians in 19 different EDs dealt with MCO ED payment denials.

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Similarly, there is some subjectivity in classifying cases as “preventable morbidity’ ’ vs “placed at increased risk.” Therefore, we summarized the cases to allow individual readers to make their own determinations. Despite this subjectivity, we believe that most readers will agree that the cases described here should not have been denied ED payment authorization. Based on the results of this paper and o t h e r ~ , ’ ~large, .~’ prospective studies should be conducted to determine the risk of adverse outcomes in patients denied payment for ED care. Such studies should ideally be performed at several sites because EDs respond heterogeneously to the competing demands of COBRA medical screening examinations and MCO gatekeeper requirements. The assumptions underlying MCO gatekeeping, i.e., that the costs of ED care are unacceptably high and the risks of triaging patients away from the ED are acceptably low, require ~ a l i d a t i o n . ~ ’ - ~ ~

I CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . .. .

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Our study suggests that MCO gatekeeping may be associated with adverse outcomes. Although the study design cannot assess the magnitude of the risk associated with MCO gatekeeping, the results suggest that gatekeeping should not be used until its safety is assessed with a large, prospective study in general hospital EDs. Pending demonstration of the safety of MCO gatekeeping, all patients seeking ED care should be evaluated in person by a physician, regardless of gatekeeping decisions made by MCO personnel. Patients must be informed of the potential risks associated with delayed care related to MCO gatekeeper recommendations. The authors thank contributing emergency physician members of the American College of Emergency Physicians (ACEP), SAEM, and the Emed-L Internet discussion list. Additional support was provided by the Washington, DC, ACEP office.

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hospital emergency and outpatient departments, United States, January-June, 1980. National Medical Care Utilization and Expenditure Survey, Preliminary Data Report No. 2. Washington, DC: US Govemment Printing Office, 1983: vol DHHS Pub. No. (PHS) 83-200000. 31. Young GP, Wagner MB, Kellermann AL, Ellis J, Bousley D. Ambulatory visits to hospital emergency departments: patterns and reasons for use. JAMA. 1996; 276:460-5. 32. Dale J, Green J, Reid F, Gluksman E. Primary care in the accident and emergency department: I. Prospective identification of patients. Br Med J. 1995; 31 1:423-6. 33. Gill JM, Reese CL, Diamond JJ. Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med. 1996; 28:474-9. 34. EMTALA, P.L., 99-272, 42 U.S.C. sec 1395 dd. 35. Federal Register, June 22, 1994:32086-32127. 36. Frew SA, Rousch WR, LaGreca KL. COBRA: implications for emergency medicine. Ann Emerg Med. 1988; 17:835-7. 37. Frew SA. COBRAEMTALA-new risks for emergency medicine and managed care (part I). Emerg Phys Legal Bulletin 1994; 5(2):1-8. 38. Frew SA. COBRAEMTALA-new risks for emergency medicine and managed care (part 11). Emerg Phys Leg Bull. 1994; 5(3):1-8. 39. Levine RJ, Guisto JA, Meislin HW,Spaite DW. Analysis of federally imposed penalties for violations of the Consolidated Omnibus Reconciliation Act. Ann Emerg Med. 1996; 28:45-50. 40. Williams RM. The costs of visits to emergency departments. N Engl J Med. 1996; 334542-6. 41. Tyrance PH, Himmelstein DU, Woolhandler S. US emergency department costs: n o emergency. A m J Public Health. 1996; 86:1527-31. 42. Abbuhl SB, Lowe RA. The inappropriateness of “appropriateness” [commentary]. Acad Emerg Med. 1996; 3:189-91.

APPENDIXA Managed Care Organization ( M C O ) Gatekeeping Process Overview Although no formal studies h a v e assessed t h e frequency of gatekeeping or the varied ways i n which it is practiced, the typical process of care for an MCO m e m b e r w h o arrives at the E D appeared t o be as follows. A f t e r the triage nurse’s evaluation, patients w h o are considered unstable are brought t o a critical care section of the ED for i m m e d i a t e care, without regard t o ability to pay. Patients w h o are deemed able t o wait minutes t o hours for care are then sent t o a registration clerk, w h o records their name, address, and o t h e r information, including their expected source o f payment. W h e n this source of payment i s an MCO, the patient is advised of the need t o call his or her primary care physician ( P C P ) f o r approval. In some EDs the triage nurse or registration clerk c o n t a c t s the PCP on the patient’s behalf; in others, the patient i s asked to m a k e the call. In some settings, administrative personnel in the PCP’s office or at the MCO office m a k e the gatekeeping decision. If the PCP or the PCP’s proxy authorizes the ED visit, this authorization is noted o n the patient’s chart, to e n s u r e reimbursement by the M C O . If the PCP denies authorization f o r t h e ED visit, most EDs explain that t h e patient may choose to be seen anyway, but that he or she m a y have t o pay out of p o c k e t for the services provided. In other words, the M C O does not formally d e n y authorization for treatment; instead, the MCO’s representative denies payment for the treatment. If the PCP or his or her designate does not re-

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spond to phone calls within a defined period (typically 30 minutes), most EDs will see the patient without authorization. In some EDs, the emergency physician is informed about all patients denied authorization for an ED visit, so that the emergency physician can evaluate the safety of allowing the patient to defer care for the presenting problem. For purposes of this study, a patient was deemed to have been denied payment authorization for ED care due to MCO gatekeeping if either the PCP or his or her proxy denied payment authorization for the visit.

2. Patient not receiving medically indicated stabilization even when offered 3. MCO requesting transfer or release of potentially unstable patient

APPENDIXB

Gatekeeper recommended the following (circle all that apply): 1. Release from ED-if so, any scheduled follow-up? 2. Patient to go to outpatient clinic or office-if so, when? 3. Transfer to another hospital-if so, via ambulance or private car?

Managed Care Gatekeeping Report Form Patient-specific Details Date and time Hospital and location Managed care organization (MCO) n p e of MCO model Patient demographics Medical record numbers Chief complaintrmajor problem(s) Final EDhospital diagnosis(es) Disposition: discharge, transfer, admit Admission: intensive care, operating room, transfer Follow-up information, if available Managed Care Gatekeeping-specific Details Gatekeeper input resulted in (circle all that apply to this case): 1. Patient not accepting medical screening examination even when offered

Gatekeeper denied to cover or approve (circle all that apply): 4. ED evaluation for patient with suspected or proven emergency condition 5 . On-call non-MCO consultant when MCO was unable to provide own consultant(s) 6. Hospitalization plus MCO refused to assume care

MCO’s gatekeeping response resulted in (circle all that apply): 1. Delay occurred in care or disposition due to MCO interaction 2. No MCO physician was available to discuss the case 3. MCO refused to authorize payment for some or all of care provided to patient Check all of the following that apply to this MCO patient’s care (and explain details below): 1. Morbidity or mortality may have occurred as a result of the MCO interaction 2. The emergency physician probably prevented morbidity or mortality that otherwise might have resulted 3. PatienUfamily tried to follow MCO policies for seeking urgent-emergent care but they were unable to receive 4. The MCO has a contract with your ED to provide emergency services to their enrollees