Healthy People 2010 - With Annotations
Clinical Preventive Care
Emergency services are a vital part of access to health care in the United States. All population groups, regardless of their socioeconomic, health, or insurance status, want to know that emergency services will be available and will function quickly and effectively when needed.(59) This broadly shared social expectation was reinforced by landmark Federal legislation, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986. EMTALA stipulates that anyone seeking care at a hospital emergency department (ED) must receive a medical screening examination for an emergency medical condition and appropriate stabilizing measures.(60)
For many people, however, a variety of barriers continue to block access to emergency departments when the need for emergency medical care arises.(9) Among these barriers are psychological and cultural factors that may keep some people, even if insured, from seeking care promptly; financial constraints that may inhibit some people, even if insured, from seeking care promptly; and shortcomings in the number, location, or capability of EDs in a specified geographic area.
A significant component of this objective is to reduce the proportion of people whose access to emergency services is blocked by their health insurance coverage or payment policies. These policies affect access to hospital emergency departments and, in some instances, use of prehospital emergency services.(61) Typically, these policies stipulate that unless an enrollee’s condition is life threatening, the enrollee or the ED must obtain authorization before an ED visit or risk that a claim for services will be denied. In some cases, claims for ED visits can be denied retroactively if they are deemed medically unnecessary. The rationale for these coverage and payment policies is clear: to manage care and contain costs. These policies, however, discourage some enrollees from receiving emergency treatment when and where it is warranted.(62)
Concerns about access barriers have prompted Federal, State, and organizational groups to seek assurances that health coverage or payment policies will provide payment when people go to an ED with acute symptoms of sufficient severity—including severe pain—such that a prudent layperson could reasonably expect that the lack of medical attention could result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Rev. 20-Aug-2001 at 07:19 hours.