Adverse Outcomes of Managed Care Gatekeeping

• Published in: Academic emergency medicine 1997-12, Vol.4 (12), p.1129-1136
• Main Authors: Young, Gary P., Lowe, Robert A.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; adverse outcome; Aged; Child; Child, Preschool; clinical practice; Eligibility Determination; emergency department; emergency medical services; Emergency Service, Hospital - statistics & numerical data; Female; gatekeeping; Health Services Research; Humans; Insurance Claim Review; Male; managed care; Managed Care Programs - economics; Managed Care Programs - standards; Middle Aged; Morbidity; Mortality; Outcome Assessment (Health Care); Pregnancy; Referral and Consultation - organization & administration; Retrospective Studies; Risk Factors; United States
• ISSN: 1069-6563; 1553-2712
• DOI: 10.1111/j.1553-2712.1997.tb03695.x

ABSTRACT Objectives: To determine whether telephone preauthorization for reimbursement of ED care (medical “gate‐keeping”) by managed care organizations (MCOs) is associated with adverse outcomes. Methods: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on‐call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) “near miss” (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. Results: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococcal meningitis in immuno‐compromised host, endocarditis, incarcerated inguinal hernia, meningococcemia, meningococcal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in p