Albion Monitor /News

HMO Members Face Greater Risks in Emergency Rooms

Monitor Wire Services

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Watch television's popular "ER" series and you'll see emergency room personnel dramatically saving lives via impromptu surgeries or brilliant evaluation of the patient's condition. But what you won't see is the moment when real life-or-death decisions are made -- as the physician calls the HMO to see if the provider will pay for treatment.

The managed care employee -- who may not have any medical training -- is called the "gatekeeper." While a HMO can't actually deny emergency medical care, the corporation can refuse to reimburse the hospital. Faced with paying astronomical medical bills by themselves, most patients leave the emergency room without additional tests or examinations that may be required to accurately diagnose their condition.

In a new study by the University of Pennsylvania Medical Center, nearly one-third of the patients who later faced life-threatening situations had been turned down by their HMO.

All "adverse outcome" cases required later emergency surgery and/or hospitalization
The study, published in the December issue of Academic Emergency Medicine, provides additional scientific evidence to support a growing concern among emergency medical personnel that patients' health is being compromised by gatekeeping procedures.

"Our findings demonstrate that managed-care gatekeeping in an emergency department environment prevents optimal patient care in many situations," notes investigator Robert A. Lowe, MD, MPH, assistant professor of emergency medicine and epidemiology at the University.

"These results suggest that further study is needed to ascertain the actual safety of gatekeeping as a medically-related practice. Indeed, like any new medically-related drug or device, the practice of gatekeeping should be evaluated scientifically for its overall safety prior to implementation in the healthcare industry."

During 1994 and 1995, the researchers -- both of whom are practicing Emergency Department physicians -- called for reports of any known incidents of negative clinical outcomes or "near misses" related to managed-care gatekeeping. Of 143 reports submitted, 114 were eliminated from the study because they involved telephone arguments between gatekeepers and emergency physicians, or later refusal by the HMO to pay.

Of the remaining 29 reports, 28 percent were classified as "adverse outcome" or "patient placed at increased risk of death or disability." The remaining 72 percent were in the "near miss" category -- cases where doctors ignored the gatekeeper's opinion and treated the patient anyway.

All "adverse outcome" cases required later emergency surgery and/or hospitalization. Among the patients refused emergency room treatment by the HMO gatekeeper were:

  • A two-year-old girl with a high fever that later had to receive intensive-care treatment for respiratory failure due to overwhelming infection
  • A 22-year-old woman with lower abdominal pain that later needed emergency surgery for ectopic pregnancy
  • A 33-year-old woman with vaginal hemorrhaging that later had a cardiac arrest and required CPR and resuscitation , followed by an emergency hysterectomy
  • A 29-year-old man with acute abdominal pain that had to undergo emergency surgery to treat a ruptured duodenal ulcer (after having presented with acute abdominal pain).

Among the "near misses" were two cases of collapsed lungs, two ectopic pregnancies, one stroke, infection of a heart valve, small-bowel obstruction, a schizophrenic crisis resulting in psychiatric hospitalization, unstable angina, and a ruptured abdominal aortic aneurysm

"Our study results raise very real questions about the assumption that gatekeeping in an ED (emergency department) setting is being practiced in a safe manner," concludes Dr. Lowe. "To that end, we recommend that our study be viewed as a 'wake-up call' to the managed-care community to design and implement scientific studies into the safety of their gatekeeping protocols.

"We also commend those HMOs that have already rejected ED gatekeeping in favor of other, more positive, strategies to reduce ED use by improving access to other sources of primary care," added Dr. Lowe.

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Albion Monitor December 23, 1997 (

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