Critical Care Medicine - List
http://www.pitt.edu/~crippen/

Gatekeeping and Triage: Different and yet the same.

Presented by Robert Marshall.

This is a "heads up" that an article in the December Academic Emergency Medicine, embargoed for release until tomorrow, will hit the national media tomorrow. Local programs may be contacted by local media for comment upon this story, or you may all wish to be proactive in readying a response for use with local newspapers and television stations.

he article is entitled " Adverse Outcomes of Managed Care Gatekeeping" by Gary Young and Robert Lowe. 143 cases of Managed care organization gatekeeper denial, referred to the authors via a national call for cases of denial with adverse outcomes were reviewed, and 29 cases were identified that represented true MCO denials with such outcomes. 4 had distinct adverse outcomes (meningiococcemia with respiratory failure, ruptured ectopic pregnancy with hypovolemic syncope, hypovolemic arrest from fibroid hemorrhage, and ruptured duodenal ulcer), 4 denials were judged to place patients at increased risk (e.g. epiglottitis, ruptured ectopic, MI, delayed treatment of hip septic arthritis), and 21 cases were defined as "near misses" (dx of ectopic pregnancy, pneumothorax, alcohol withdrawal seizures + pancreatitis, appendicitis, bacterial meningitis, CVA, endocarditis, incarcerated inguinal hernia, meningiococcemia and meningiococcal meningitis, ruptured AAA, SBO, unstable angina,etc).

The press release from the University of Pennsylvania is attached. SAEM has produced its own media release, which is being released on the wire services today. The main "talking points" are:

1. While managed care organizations grapple with cost containment, the legal and clinical risks posed by gatekeeping is potentially jeopardizing the health of patients. A CONSUMER SAFETY ISSUE.

2. Telephone gatekeeper preauthorization cannot accurately assess medical conditions of patients seeking emergency care - adverse outcomes will occur without emergency physician intervention.

3. Until it is proven that managed care providers can safely implement a gatekeeping policy, all patients seeking emergency care should be evaluated in person by an emergency physician, and patients should be informed of potential risks associated with delayed care related to gatekeeper recommendations. UNTIL WE CAN SAY IT'S SAFE, WE SHOULDN'T BE DOING THIS.

4. Importance of access to health care should be emphasized.

Please be ready in case you are contacted by local media, or be proactive about being available. Thanks for your help.

FROM THE UNIVERSITY OF PENNSYLVANIA.

Our study is not definitive but raises enough questions to warrant the conclusion that managed care gatekeeping is potentially dangerous and should not be adopted unless and until it is proven to be safe. Not all HMOs are bad: We want to work with the managed care community to ensure access to care, in the ED and in traditional primary care settings.

Here's the release:

Contact: Rebecca Harmon (215) 349-5660, harmonr@mail.med.upenn.edu Embargoed Until: Tuesday, December 2, 1997

MANAGED-CARE "GATEKEEPING" OF EMERGENCY MEDICAL CARE RESULTS IN ADVERSE CLINICAL OUTCOMES FOR PATIENTS

Study Challenges the Untested Safety of Gatekeeping Practices.

(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.

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. (Not all HMOs have such a requirement, however.) 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. 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 payment. 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.

"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 'call to action' to the managed-care industry.

David Crippen:

Bob Marshall said: "Telephone gatekeeper preauthorization cannot accurately assess medical conditions of patients seeking emergency care - adverse outcomes will occur without emergency physician intervention".

I don't think that is the reason why telephone triage has failed. Remember that most patients desiring admission to most emergency departments do not have emergencies. They come because it is convenient, they know they have to be seen and a big chunk of them know they don't have to pay for it.

The main reason it doesn't work is simply because the phone gatekeepers routinely approve ANY visit shortly after the prospective patient pitches a fit and demands to be seen for his or her particular non-emergent complaint. If you pitch a fit and threaten to write letters and make phone calls, they all fold immediately simply because they don't t want the hassle. Then what happens is managed care pays for both the non-emergent complaint in an expensive emergency setting AND the cost of the gatekeper who failed to divert them.

Marshall: "Until it is proven that managed care providers can safely implement a gatekeeping policy, all patients seeking emergency care should be evaluated in person by an emergency physician, and patients should be informed of potential risks associated with delayed care related to gatekeeper recommendations".

I don't believe this statement, although it has become a war cry for the American College of Emergency Physicians, an organization equally as interested in full employment for emergency physicians as it is in providing good emergency care. There have been several seemingly good studies that have shown that patients arriving at emergency departments with non-emergent complaints can be effectively triaged to other area where they can receive the same care, much more cost effectively.

The issue is not patient safety; the issue is maintaining and increasing a supply of patients to match the increasing supply of emergency physicians. The ACEP has tried numerous plans to divert the the issue of inappropriate ED admissions. The first is, of course, the big statistical scam......that it doesn't cost any more to deal with snotty noses in an ED than in a practitioners office. This was greeted by a round of guffaws from those who know. Then came the concept of "Fast-Tracks" in the ED to handle non-emergent convenience complaints. When lift the skirts of "Fast-Track" however, you find that the whole point is pushing more of them through the system faster; each is usually charged the same as emergency patients. There is no cost savings, it is a method of attracting more of them. I think someone at ACEP actually advocated encouraged convenience clinic patients to come to EDs in the middle of the night when there is more time available to deal with them. ACEP doesn't want to divery convenience complaints from EDS, they want to supply more physicians to deal with them and they want someone else to pay for it.

Dick Burrows:

Sorry FL but I disagree (again). Not fighting with you but triage on the basis of a telephone call fails for the simple reasons:

1. It's impossible for the gatekeeprer to examine the patient.

2. It's impossible to verify the story of the referring person without examining the patient.

I am sure that you would want to do that wouldn't you. You wouldn't want to commit a patient to an irrevocable decision on the basis of a telephone would you.

David Crippen:

We are closer on this issue than you think. I don't think telephone triage is effective either, but for many more reasons than are currently given. Telephone triage is a manuver for managed care to save money on inappropriate admissions but retain control on their end. They don't trust the emergency medicine industry to do it because the ED industry has a VERY strong incentive to admit anyone who shows up for any reason if someone, somewhere will pay for it.

What I think can be effective is triage at the point of entry by the people managing the emergency service. An experienced triage nurse can spot complaints that are clearly inappropraite for acute care settings. Any grey areas can be quickly and informally eyeballed by the doc for confirmation. Try running this idea past any of the big emergency services that make their money ona volume business suvh as Spectrum, Coastal or Emcare and see how fast you are taken out to the parking lot by either shills or watchdogs and given a quick, impersonal lecture on the cost of dental work and the difficulties of trying to eat with two broken arms.

Dick Burrows:

I think it is important for the Medical Man to define exactly why he is making a decision to triage.

Pelligrino (1986) has defined 3 forms of gatekeeping:

1. Defacto gategeeping which he defines as "Diagnostic elegance and therepeutic parsimony" is ethically correct.

2. Negative gatekeeping wherein therapeutic modalities are denied because of budget constraints "the bottom line" is ethically suspect.

3. Positive gatekeeping wherein the patient is encouraged to have the operation in the hospital/clinic where the Medical Man has shares is definitely unethical.

Clearly 1&2 are going to drift into each other to some extent and the line between them may be a fine one. None the less it is our duty to look critically at those forms of treatment that confer marginal benefits, if any benefit for that matter, and not use them (?ECMO). Clearly this eventually becomes a statistic (Lantos) as to when one is comfortable to make a decision to triage on the basis of futility of treatment (70% suggested by Paris?) On the other hand if Medical Man is simply the front man for Admin Man's messengers of death crawling along the bottom line then screw Admin Man - he can do his own bloody dirty work.

David Crippen:

I also agree mostly with Ed Pelligrino who I truly believe is one of the GREAT physician role models of our time. I would encourage everyone to read anything Ed Pelligrino has to say on anything.

Here is my rant: The REAL point of triage is to match expensive resources to true need. Physicians offices and hospital clinics are supplied with the equipment and personnel to fine tune chronic complaints, nip emerging urgencies in the bud and identify problems requiring specialty care. In offices and clinics, there is no need to to stockpile expensive hardware and more highly trained, (read: expensive) personnel on a 24 hour per day basis. To purchase this technology and expertise would drive the price of triage up inordinantly. Any patient requiring this technology and expertise is transferred to a facility where these items are centralized. Facilities dealing with emergencies must stockpile expensive, costly to maintain hardware and highly trained (read: expensive) personnel 24 hours a day, since real emergencies cannot be predicted. The cost of all this stuff must be passed on to the consumers utilizing it.

So consumers can have it one way or the other. They can be directed to a center whose purpose is the treatment of complaints not requiring expensive modes, and referral to an emergency center only if questionable urgencies are, in fact, veiled emergencies. The cost for this kind of system is nominal. Or everyone can go to their nearest "emergency" center for everything, and anything...and bear the additional cost. You cannot have both. There are at least four reasons why a phenomenally expensive "open door policy" within the Emergency Medicine Industry exists.

1) Payers are currently willing to finance convenience as a maxim rather than effectiveness because their patient population demands it. The reason they demand it is because the Emergency Medicine Industry widely advertises freely available physician presence for all comers and facilitates ease of entry. "If you think it's an emergency, we're here to help you".

2) They have bought into the proposition that ANY false positive is unacceptable. "But what if my cold is really meningitis?". And so they are willing to pay to evaluate 10,000 snotty noses in an expensive emergency setting to catch one meningitis masquerading as a snotty nose. A proposition infinitely more expensive that simply settling the obligatory lawsuit from any such false positive.

3) Attending physicians "use" the emergency department to take the heat off their patient phone calls, especially at night. I know at least two town physicians who (at least in the past) attached phone recordings to every incoming call....."If you are sick and feel you need care, go to the emergency room". Others use the ED as their personal triage device. They train their patients to come to the emergency room for any complaint, and have a very low threshold for getting them admitted, knowing they will eventually be reimbursed for some kind of care. They also refer them to the ED for admission, asking the ED physician to do all the work.

4) Factions of "poor and disadvantaged" know they have to be seen for anything they want, for as long as they want, they can't be turned away and they don't have to pay a thin dime for it. Any attempt to limit their access will be met by loud cries of discrimination from their political lobby groups. They have the best medical insurance in existence. Blue Cross card holders DREAM about having insurance like that.

THAT's what you're bucking when you talk about limiting access for clearly inappropriate complaints to expensive emergency departments.

Now, Managed Care, by it's nature, is not only interested much more in conserving it's lucre than it is spreading it around effectively. They quickly figured out that inappropriate ED admissions cost (them) a bundle. But remember that the nature of managed care is management. They don't trust providers to limit provision because providers have a financial incentive to supply a demand......Hell, even to induce demand. Allowing these same providers to limit demand is like asking your barber if you need a haircut. So telephone triage (with the managed care wonk doing the triaging from afar) became the norm.

Two kinds of costly slop quickly appear in telephone triage:

1) Inappropriate phone acceptance of false positives: Patients with clearly bullshit complaints allowed access because they pitch a fit and make waves, or the gatekeeper is a wimp. So managed care pays for both the admission and the cost of the triage.

2) 1) Inappropriate phone diversion of false negatives: Patients with authentic emergencies masquerading as urgencies diverted due to lack of sensitivity in the assessment process. Then managed care pays a bundle in lawsuits and administrative hassles.

So, assuming you think inappropraite access to specialized care is a problem, how do you fix it?

It is quite simple, you simply allow the age old process of "triage" to work at the point of entry, using an experienced triage nurse (with physician backup) to make a determination of what is the right thing to do. Inappropriate applicants are simply told this isn't the right place for their complaint and they are made an appointment to clinic or to a local physician's office next possible opening.

Yes....you generate a lot of pissed off people because the Emergency Medicine Industry has led them to believe the ED is there for anything they want to use it for (with someone else paying the bill)...yes one in 10,000 snotty noses will turn out to be meningitis in disguise and lawyers will flock to scene like flies to shit but, in the end, it is still cheaper and more effective than opening the door to all comers.

Mercifully for all of you, this is all I have to say on the subject. How emergency services are run in this county ROYALLY pisses me off and I tend to rant.

Fini.