Anthem, one of the largest healthcare insurers in the United States, implemented an “avoid-able ER” policy to help manage the care of its enrollees. The policy stated that Anthem would not pay for emergency room visits if the company determined that the visit was not necessary. The policy, which was instituted in six states beginning in 2015, was meant to encourage patients to seek care in appropriate settings. However, providers feel that this policy might cause patients to avoid emergency treatment, even when it is necessary. In response to customer and provider complaints, Anthem created several exceptions: Claims will be covered if a healthcare provider tells a patient to go to the emergency room, if the patient is under 15 years of age, if the patient is outside his or her state of residence, and if the patient had a CT scan or MRI or underwent surgery. Still, providers are unhappy with the policy (Livingston 2018).
Discussion Questions
- Why did Anthem implement this policy? 2. How is this policy an example of managed care? 3. What other solutions could be used to minimize costs but ensure access and quality?
