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Coverage disputes and the prudent layperson standard
CORRESPONDENCE
a result of the intermittent fever curve induced by SARS infection. Second, fever may be the only initial presentation of SARS. Of our SARS patients, 13.9% (11/79) reported fever as the only symptom in the ED, yet 9 of them had radiographic infiltrates. Were it not for the practice of regularly checking body temperature, they might be regarded as cases ‘‘with radiographic evidence of pneumonia preceding the fever.’’ Thus, from our experience, we believe that routinely measuring body temperature provides an important step in the early detection and screening of potential SARS infection. Finally, although a detailed time sequence of radiographic progression might be theoretically useful in the diagnosis of SARS, this information was nearly unavailable in the ED. More importantly, our purpose of proposing this model was to provide an aide to shape triage decisions in case of mass casualty management, rather than to make definite diagnosis in the ED. Shey-Ying Chen, MD Chan-Ping Su, MD Wen-Chu Chiang, MD Ting-I Lai, MD Wen-Jone Chen, MD, PhD Department of Emergency Medicine National Taiwan University Hospital Taipei, Taiwan doi:10.1016/j.annemergmed.2004.02.048 1. Fisher DA, Lim TK, Lim YT, et al. Atypical presentations of SARS [letter]. Lancet. 2003;361:1740. 2. Peiris JS, Yuen KY, Osterhaus AD, et al. The severe acute respiratory syndrome. N Engl J Med. 2003;349:2431-2441. 3. Peiris JSM, Chu CM, Cheng VCC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003;361:1767-1772. 4. Chen SY, Chiang WC, Ma MHM, et al. Sequential symptomatic analysis in probable severe acute respiratory syndrome cases. Ann Emerg Med. 2004;43:1-7. 5. Nicholls JM, Poon LLM, Lee KC, et al. Lung pathology of fatal severe acute respiratory syndrome. Lancet. 2003;362:1773-1778.
emergency care unless ‘‘the patient should have known that they did not have an emergency.’’2 This language is uniquely subjective in that it refers to the patient’s frame of mind rather than to ‘‘the opinion of a prudent layperson.’’ Because it would be very difficult to prove a negative on the basis of what the patient should have known, the frequency of denials should have been much lower if these plans were obeying the law. In addition, a statement in the accompanying editorial by Stapczynski3 deserves clarification. He compares postvisit review to efforts to reduce ED visits by requiring preauthorization, noting a similar lack of utility. The inference is that the practice of pre-authorization for ED visits was abandoned because it wasn’t useful, or perhaps that it was unsafe or inaccurate per the references cited. On the contrary, managed care gatekeeping was primarily abandoned not because it lacked utility for health plans, but because of complaints and regulatory activity instigated by providers and consumers. For example, prior authorization in the ED was prohibited after emergency physicians in California convinced the Office of Inspector General that it was a violation of the Emergency Medical Treatment and Active Labor Act.4 These comments illustrate the importance of placing socioeconomic data in the appropriate historical and legal context. Loren A. Johnson, MD Emergency Department Sutter Davis Hospital Davis, CA doi:10.1016/j.annemergmed.2004.03.044
Coverage Disputes and the Prudent Layperson Standard
1. Gresenz CR, Studdert DM. Disputes over coverage of emergency department services: a study of two health maintenance organizations. Ann Emerg Med. 2004;43: 155-162. 2. California Health and Safety Code 1371.4 3. Stapczynski JS. Is the prudent layperson standard really a ‘‘standard’’? Ann Emerg Med. 2004;43:163-165. 4. Office of Inspector General/Health Care Financing Administration Special Advisory Bulletin on the Patient Anti-dumping Statute Related to Managed Care Plans, 64 Federal Register 61353-61359 (1999).
To the Editor:
In reply:
In the February 2004 issue of Annals, Gresenz and Studdert1 provide interesting insight into the health plan denial and appeal process; however, it should be noted that this study was conducted under the premise that California has a prudent layperson standard for insurance coverage of emergency department (ED) visits. Actually, California has a more generous standard for ED access than the conventional prudent layperson standard, wherein the law states that a health plan (excepting Kaiser) must pay for
The defining feature of a prudent layperson standard is its reference to ex ante expectations of patients, as opposed to professional judgment, as the basis for determining the appropriateness of emergency department (ED) use. A prudent layperson standard operates in California. Dr. Johnson suggests that the statutory formulation of the prudent layperson standard in California implies a more generous standard for access to ED services than other states, one that is ‘‘uniquely subjective.’’
4 2 6
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
a result of the intermittent fever curve induced by SARS infection. Second, fever may be the only initial presentation of SARS. Of our SARS patients, 13.9% (11/79) reported fever as the only symptom in the ED, yet 9 of them had radiographic infiltrates. Were it not for the practice of regularly checking body temperature, they might be regarded as cases ‘‘with radiographic evidence of pneumonia preceding the fever.’’ Thus, from our experience, we believe that routinely measuring body temperature provides an important step in the early detection and screening of potential SARS infection. Finally, although a detailed time sequence of radiographic progression might be theoretically useful in the diagnosis of SARS, this information was nearly unavailable in the ED. More importantly, our purpose of proposing this model was to provide an aide to shape triage decisions in case of mass casualty management, rather than to make definite diagnosis in the ED. Shey-Ying Chen, MD Chan-Ping Su, MD Wen-Chu Chiang, MD Ting-I Lai, MD Wen-Jone Chen, MD, PhD Department of Emergency Medicine National Taiwan University Hospital Taipei, Taiwan doi:10.1016/j.annemergmed.2004.02.048 1. Fisher DA, Lim TK, Lim YT, et al. Atypical presentations of SARS [letter]. Lancet. 2003;361:1740. 2. Peiris JS, Yuen KY, Osterhaus AD, et al. The severe acute respiratory syndrome. N Engl J Med. 2003;349:2431-2441. 3. Peiris JSM, Chu CM, Cheng VCC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003;361:1767-1772. 4. Chen SY, Chiang WC, Ma MHM, et al. Sequential symptomatic analysis in probable severe acute respiratory syndrome cases. Ann Emerg Med. 2004;43:1-7. 5. Nicholls JM, Poon LLM, Lee KC, et al. Lung pathology of fatal severe acute respiratory syndrome. Lancet. 2003;362:1773-1778.
emergency care unless ‘‘the patient should have known that they did not have an emergency.’’2 This language is uniquely subjective in that it refers to the patient’s frame of mind rather than to ‘‘the opinion of a prudent layperson.’’ Because it would be very difficult to prove a negative on the basis of what the patient should have known, the frequency of denials should have been much lower if these plans were obeying the law. In addition, a statement in the accompanying editorial by Stapczynski3 deserves clarification. He compares postvisit review to efforts to reduce ED visits by requiring preauthorization, noting a similar lack of utility. The inference is that the practice of pre-authorization for ED visits was abandoned because it wasn’t useful, or perhaps that it was unsafe or inaccurate per the references cited. On the contrary, managed care gatekeeping was primarily abandoned not because it lacked utility for health plans, but because of complaints and regulatory activity instigated by providers and consumers. For example, prior authorization in the ED was prohibited after emergency physicians in California convinced the Office of Inspector General that it was a violation of the Emergency Medical Treatment and Active Labor Act.4 These comments illustrate the importance of placing socioeconomic data in the appropriate historical and legal context. Loren A. Johnson, MD Emergency Department Sutter Davis Hospital Davis, CA doi:10.1016/j.annemergmed.2004.03.044
Coverage Disputes and the Prudent Layperson Standard
1. Gresenz CR, Studdert DM. Disputes over coverage of emergency department services: a study of two health maintenance organizations. Ann Emerg Med. 2004;43: 155-162. 2. California Health and Safety Code 1371.4 3. Stapczynski JS. Is the prudent layperson standard really a ‘‘standard’’? Ann Emerg Med. 2004;43:163-165. 4. Office of Inspector General/Health Care Financing Administration Special Advisory Bulletin on the Patient Anti-dumping Statute Related to Managed Care Plans, 64 Federal Register 61353-61359 (1999).
To the Editor:
In reply:
In the February 2004 issue of Annals, Gresenz and Studdert1 provide interesting insight into the health plan denial and appeal process; however, it should be noted that this study was conducted under the premise that California has a prudent layperson standard for insurance coverage of emergency department (ED) visits. Actually, California has a more generous standard for ED access than the conventional prudent layperson standard, wherein the law states that a health plan (excepting Kaiser) must pay for
The defining feature of a prudent layperson standard is its reference to ex ante expectations of patients, as opposed to professional judgment, as the basis for determining the appropriateness of emergency department (ED) use. A prudent layperson standard operates in California. Dr. Johnson suggests that the statutory formulation of the prudent layperson standard in California implies a more generous standard for access to ED services than other states, one that is ‘‘uniquely subjective.’’
4 2 6
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004