Study lauds emergency "prudent layperson" laws

Washington -- Patients can be prudent about their need to visit the emergency department.

That is the conclusion of a new study showing that adoption of "prudent layperson" laws enacted in 47 states in recent years didn't lead to a surge in inappropriate use of EDs by managed care patients.

The laws generally require that the urgency of a patient's condition be judged based on presenting symptoms, and that the symptoms reasonably warrant immediate attention, from the perspective of an ordinary person.

"Prior to the laws, most managed care plans would determine the necessity for emergency care based more on ultimate diagnosis than on the symptoms that prompted patients to seek emergency care," said Mark Hall, professor of law and public health at Wake Forest University in North Carolina and author of the study, published in the May Annals of Emergency Medicine.

The laws were spurred by incidents of patients with genuine acute illness who delayed care for fear of being stuck with the hospital bill, said John C. Nelson, MD, president-elect of the American Medical Association.

While there were likely few cases in which someone having a heart attack sat in the hospital parking lot debating whether to go in, prudent layperson provisions "swung the pendulum the other way," he said, allowing patients to be safe rather than sorry.

Mandates now widespread

The study was based on interviews with 87 stakeholders, including insurers, regulators, physicians and other medical professionals, patient advocates, and industry observers. It found that prudent layperson mandates have spread beyond just plans that are covered by state law.

"We found these laws were a catalyst for industrywide change, and most respondents believed basic compliance with the standard is widespread," Hall said.

The study also noted that managed care plans had not been able to develop a systematic way of evaluating claims based on symptoms, rather than on diagnoses or services. This has led health plans to approve nearly all emergency claims, either initially or after receiving an appeal.

"Patients who have reason to believe there is an immediate threat to life or health should go directly to the nearest ER," said Susan Pisano, spokeswoman for America's Health Insurance Plans. "We also support appropriate use of the ER so that ER personnel can devote their attention to those in need of ER-level services."

The question remains, however, whether many patients show up in the emergency department, not because of true emergencies, but because they don't have a relationship with a primary care physician and don't know where else to go for help, she said.

Hall's study looked at that issue. The respondents reported that although there was little change in inappropriate use of emergency services, it was still high, most likely due to a lack of access to primary care.

He found that insurers had attempted to compensate for the change in claims-approval policies by raising the co-payment for emergency visits. Whether that has been effective is unclear, but the laws have not caused a significant increase in overall health insurance costs, undermining insurers' warning that mandates mean higher premiums.

"It's not our intention to hurt insurers; it's not our intention to hurt HMOs," Dr. Nelson said. "It's our intention to help patients."

Despite the laws' success, work still needs to be done, said J. Brian Hancock, MD, president of the American College of Emergency Physicians.

"State prudent layperson laws, as this study points out, may be effective in preventing denials of coverage for emergency services, but there are still significant pockets where health insurers haven't changed their practices," he said.