ACEP Initiative Supporting 'Prudent Layperson' Standard Becomes Law in Health Care Reform Act

May 2010

By Linda Blachly
ACEP News Contributing Writer

The American College of Emergency Physicians has worked tirelessly for more than 17 years for a passage of a national "prudent layperson" standard to require health insurance plans to base coverage of emergency care on a patient's symptoms, not the final diagnosis.

After a long journey and a tough fight, the newly passed health care reform legislation applies this standard to nearly 100% of all the health plans in America.

The standard was included as part of an amendment called the Patients' Bill of Rights, sponsored by Sen. Benjamin L. Cardin (D-Md.). Sen. Cardin is the champion and original congressional sponsor of the ACEP-supported bill in 1995 to enact a national prudent layperson standard, which was applied to Medicare and Medicaid in 1997.

ACEP has always been a leader at the national and state levels in advocating for the prudent layperson standard.

A "prudent layperson" has been defined in the law as one who possesses an average knowledge of health and medicine, and the standard establishes the criteria that insurance coverage is based not on ultimate diagnosis, but on whether a prudent person might anticipate serious impairment to his or her health in an emergency situation.

"ACEP has long believed that anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency," said Dr. Angela Gardner, ACEP President.

"The new bill also prohibits health plans from requiring patients to seek prior authorization before seeking emergency care, which is also part of that standard," she added.

In the past, most managed care plans would determine the necessity for emergency care based on the final diagnosis, rather than on the symptoms that prompted patients to seek emergency care.

For example, a person with a severe headache and blurred vision might be denied coverage for an emergency visit because the condition turned out to be minor and easily treated.

ACEP argued against this, saying it was prudent for the person to seek care, because these symptoms can be indications of life-threatening conditions.

Cal Chaney, ACEP General Counsel and Executive Associate Director of ACEP's Policy Division, said he remembers when he and ACEP leaders traveled from state to state, in many cases helping ACEP chapters start or enhance legislative programs to advocate for the standard at the state level.

"As a result of this initiative, many chapters hired lobbyists for the first time, initiated political action committees, held legislative days at their state capitols, trained their members to lobby, and established collaborative relationships with elected officials, key decision makers, and other medical and consumer groups," Mr. Chaney said.

"It energized ACEP and the chapters, and resulted in an impressive increase in membership during that period," he added.

The driving force behind much of the success at the state and national levels was the stories of patients, including the following:

  • A 46-year-old Detroit woman collapsed in her husband's arms and was rushed to the hospital by ambulance, but died of cardiac arrest after emergency physicians worked to revive her for 30 minutes. Her managed care plan denied payment for treatment because she did not call for prior approval.
  • A 44-year-old Illinois man with chest pain and shortness of breath called his managed care plan for authorization to go to the emergency department. The plan representative told him not to "worry about it." One hour later, he was transported to the ED, where he died of a heart attack.

In 1993, Maryland was the first state to adopt its own prudent layperson laws. In following years, a total of 47 states enacted some form of the prudent layperson standard, resulting in coverage of an estimated 207 million Americans.

"State actions were important, but they did not apply to millions of people in health plans covered by the Employee Retirement Income Security Act or the millions of federal employees," Dr. Gardner said. "That's why ACEP continued to advocate for a national standard that applies to all health plans, which has finally been achieved."

Intense pressure from ACEP generated responses from health plans to offer to apply the standard voluntarily. Voluntary measures worked to a point but were not enforceable, and the economic pressures of keeping costs down were too great to make a voluntary approach a realistic solution.

Throughout the 1990s, Congress sought to pass patient protection legislation. By the late 1990s, ACEP was successful in its efforts to gain bipartisan agreement that the prudent layperson standard should be included in any version of a patients' bill of rights.

ACEP led a grassroots effort to recruit more than 35 national medical organizations to support the standard. Several ACEP presidents and other leaders testified before Congress in support of the standard. ACEP's 911 Network members, through their lobbying efforts, helped garner congressional support for the standard.

As part of the Balanced Budget Act of 1997, Congress enacted this standard for Medicare and Medicaid managed care plans.

The prudent layperson standard was also extended to all federal employees in 1999. The standard required health plans to cover emergency services if a prudent layperson believed he or she was experiencing a medical emergency. In such cases, prior authorization from the plan is not required.

"Achieving adoption of the prudent layperson standard has been a priority of ACEP since 1993. It was the intense focus of our advocacy and media activities for so many ACEP leaders at the state and national level--and was vehemently opposed by health plans state by state for many years," Dr. Gardner said.

"To see this patient-centered ACEP initiative become the law of the land is a tremendous achievement for emergency medicine," Dr. Gardner concluded.

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