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Good News That Could Be Deadly

Health Insurance

In 2017 news was shared that Anthem Blue Cross Blue Shield had intended on beginning a new payment scheme reimbursing EMS agencies for not transporting patients to the hospital, where it was appropriate. Anthem is the first major insurer in the United States to begin to offer such a service. As a result, excitement has increased that, in addition to the increase in reimbursement, there may be a reduction in transports to the emergency department which were, clinically, not necessary. According to Dr. Jay Moore, senior clinical medical director for Anthem in the state of Missouri, the plan is to use this as a springboard to invest in expand in community pair medicine. According to More, “we’re interested in engaging with progressive EMS providers who are interested in doing things beside the traditional fee-for-service model “.

This is indeed good news for the states in which it will be rolled out which include the Commonwealth of Kentucky. However, an interesting twist to this has developed in our state that also involves Anthem Blue Cross/Blue Shield. A recent news story, shown on WKYT in Lexington, revealed that Anthem Blue Cross/Blue Shield is now beginning to deny reimbursement to patients who go to the emergency department if the insurance company determines, AFTERWARDS, that their illness is not an emergency. This holds some interesting opportunities as well as some possible pitfalls for EMS crews in our state as well as any others in which this policy might be in effect.

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I anticipate that patients will begin calling EMS more for a preemptory assessment to determine whether or not the EMS crew feels that their symptoms warrant a transport to the hospital. An unintended effect of this decision, by the insurer, could be that calls may actually increase for EMS agencies while transports decrease. This may be because patients will self-determine, based upon the advice given by the EMS crews, that they will not go to the hospital out of fear of a claim denial resulting in an ED bill of several thousands of dollars.

The legal liability dangers of a poorly assessed patient, in this particular type of scenario, are many. I’ve always said that the most important skill that any medical provider must have is the ability to do an adequate and rapid patient assessment. Too often, I’ve seen EMS providers that are either unable to or unwilling to do this. As a result, we may see patients who really need to go to the hospital being left at home with conditions that may worsen if the assessment is not completed correctly by the EMS responder.

It behooves us as, medical professionals, to make sure that our ability to assess a patient is top notch. Many times, we feel that simply because we may have responded to a, self-determined number of calls each year, this alone allows them to be experts in the area of assessment. This may hold true, but, to my knowledge, there is been no scientific research that shows that an unknown number of calls run over the course of 12 months insures that a responder is competent in the arena of patient assessment. This is where the idea of professionalism and pride in the profession should step in for each of us.

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The opportunity to be able to treat patients and leave them at home, when it is appropriate, is a very large step in the right direction for our profession.  It will help us to be recognized as a member of the medical profession. Keep in mind that all EMS responder should seek to do what is best for their patients. This means we should periodically refresh our assessment abilities, especially in the areas of subtle changes, found within the patient that may be deadly for them if you have left them unattended.


About the Author

Dr. Bill Young began his EMS career in 1975 with a small fire department near Williamsburg, KY. They began running first responder calls long before the phrase ever existed. In addition to Kentucky, his career has taken him to Tennessee, Colorado, Georgia, and Kansas. He has served as a street medic, training officer, supervisor, state regulator, and educator. Currently, he is an Associate Professor and the Director of the Department of Paramedicine at Eastern Kentucky University.

Published on February 02, 2018

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