Managed-Care

December 02, 1997

(Philadelphia, PA) -- In a nation-wide review of the practice of gatekeeping by managed-care companies, researchers found that -- among 29 reported cases of adverse clinical outcomes -- nearly one-third (28%) of patients who were denied telephone pre-authorization for emergency medical care suffered adverse clinical outcomes or were put at an increased risk of death or disability. In addition, the majority of patient-cases reviewed (72%) were categorized as "near misses" -- i.e., cases in which emergency physicians prevented an adverse outcome or increased risk by caring for the patient despite denial of reimbursement by the managed-care organization or HMO (health-maintenance organization).

The study, to be 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 as a result of common gatekeeping activities. "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 of Pennsylvania Medical Center. "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."

Gatekeeping is the process by which many HMOs authorize or deny reimbursement of emergency care for their insured patients. Typically, emergency department (ED) personnel are required to contact by phone the on-call representative -- or gatekeeper -- for the managed-care company that insures the patient. (Not all HMOs have such a requirement, however.) The gatekeeper, who may or may not have medical knowledge or training, is then responsible for assessing a patient's medical condition in order to authorize ... or deny ... reimbursement of emergency treatment. Although managed-care companies may not deny care -- only reimbursement -- denial of reimbursement discourages most patients from continuing to seek treatment at the time they present to an emergency department.

According to the research team, the issue of gatekeeping safety is further compounded by the process used to redirect patients away from emergency care. "Most prudent individuals agree that medical assessments should be made in person by specially-trained physicians and nurses," says investigator Gary P. Young, MD, an emergency physician at the Sacred Heart Medical Center in Eugene, Oregon. "Thus, we were not surprised to find that telephone gatekeeping -- even by physicians -- did not reliably distinguish patients who could safely be denied ED care. For that reason, we recommend that all patients who seek emergency care be evaluated in person by a physician, regardless of gatekeeping decisions by managed-care personnel."

Research Methodology

During 1994 and 1995, the researchers -- both of whom are practicing Emergency Department physicians -- invited their professional colleagues to report to them any known incidents of negative clinical outcomes or potential negative clinical outcomes related to managed-care gatekeeping. Case reports were solicited from four different sources, including three professional organizations and one Internet emergency medicine discussion group. Inclusion criterion was that, at the time of presentation to the emergency department, the patient must have been denied authorization for emergency care by a gatekeeper representing the patient's HMO insurer. Of 143 reports submitted, 114 were eliminated by researcher-agreement from further consideration because they described, for the most part, telephone arguments between managed- care gatekeepers and ED physicians, or retrospective denials of payments. Of the remaining 29 reports, four cases (or 14%) were classified as "adverse outcomes;" four more (14%) were categorized "patient placed at increased risk of death or disability;" and the remaining 21 cases (72%) satisfied the criteria for inclusion in the "near miss" category.

In all four "adverse outcome" cases, the patients were denied reimbursement for emergency care by their managed-care insurer at the time they initially presented themselves to Emergency Department personnel. Subsequently, each one sustained a life-threatening "adverse outcome" that needed to be corrected by some type of emergency surgery and/or hospitalization. For example, a two-year-old girl had to receive intensive-care treatment for respiratory failure due to overwhelming infection (after having presented for a high fever); a 22-year-old woman required treatment for shock followed by emergency surgery to correct a ruptured ectopic pregnancy (after having presented with lower abdominal pain); a 33-year-old woman had a cardiac arrest and required CPR and resuscitation , followed by an emergency hysterectomy (after having presented with vaginal hemorrhaging); and a 29-year-old man had to undergo emergency surgery to treat a ruptured duodenal ulcer (after having presented with acute abdominal pain).

Some of the "near misses" included 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

Wake-Up Call

"Our study results raise very real questions about the assumption that gatekeeping in an ED 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.

# # #

University of Pennsylvania School of Medicine

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