Annals of Emergency Medicine
Volume 36, Issue 3 , Pages 238-240, September 2000

The Prudent Layperson Definition: Will It Work for Emergency Medicine?☆

Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI

Article Outline

Abstract 

[Williams RM. The prudent layperson definition: will it work for emergency medicine? Ann Emerg Med. September 2000;36:238-240.]

 

See related article, p. 212 .

Passage of prudent layperson legislation has been a major focus of organized emergency medicine in recent years. About 30 states have passed such legislation, and the prudent layperson definition is included in the Balanced Budget Act of 1997 for Medicaid and Medicare patients. Many emergency physicians consider this language to be a solution to the reimbursement issues involving managed care. In this issue of Annals , Shesser et al1 present their findings regarding classification of emergency department visits as a presenting symptom–based system based on the prudent layperson criteria, compared with final diagnosis–based system used by a managed care organization (MCO). This is an interesting and important study in that it provides an examination of how application of the prudent layperson standard might work in practice.

For decades, emergency physicians accepted the premise that patients were the best judges of their welfare. Hospitals and emergency physicians were absolved of any responsibility of classification of medical necessity by accepting that everyone who showed up at the ED, by patient definition, was a legitimate emergency visit. In recent years, the phenomenal growth of managed care and the use of stringent retrospective criteria to determine payment for emergency services have rendered this deemed approach invalid, and have resulted in conflict between emergency physicians and MCOs. A major issue for emergency physicians is whether the prudent layperson language will resolve these reimbursement issues. The article appearing in the current issue of this journal gives a first look of how the prudent layperson approach might function with regard to defining an insurable event.

What is a medical emergency? Although there has been increasing interest among emergency physicians, policymakers, and insurers in defining ED use by level of the patient’s condition severity, there are no accepted standard classification criteria for determining patient urgency. During the past 40 years, numerous authors have used a variety of objective and subjective criteria to classify ED patients as urgent or nonurgent.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 Many policymakers have focused on a 1994 National Center for Health Statistics study that reported 55% nonurgent ED use.17

An important but frequently overlooked aspect is why patients seek care in the ED. The perception of the seriousness of symptoms varies among individuals and groups, and patients seek care for a multitude of personal, cultural, financial, and social reasons. Several attributes of care that have been shown to influence the decision to seek emergency services include convenience, cost, waiting time for treatment, and perceived quality of medical care delivered.18, 19, 20

In the study by Shesser et al,1 the authors examined nearly 2,000 records from a busy urban ED that contracts with a university-sponsored MCO plan. Records were evaluated under 2 sets of criteria. One evaluation was based on existing nurse triage criteria for urgent and emergency patients, combined with review by an emergency physician for less-urgent patients according to the prudent layperson guidelines. The same records were also assessed according to prior existing criteria of the MCO plan that were based on the final International Classification of Diseases, ninth revision diagnosis.

The authors found that nearly 80% of all visits met the prudent layperson standard compared with 53% by the diagnosis-based MCO criteria. The authors conclude that use of symptom-based criteria based on the prudent layperson language results in a higher proportion of approved visits for insurance payment purposes and suggest that use of such a symptom-based plan would satisfy MCOs and consumers.

There are a number of important limitations to the study. The patients in this study were seen at a busy urban ED and were insured by a university-sponsored MCO plan. It is possible that patients in this plan are atypical compared with other MCO plans. Of considerable importance is what happens to the patients who end up in the “suspended” category that amounted to nearly one third of all patient visits. The authors provide no guidance or historical perspective of the resolution of these patients whose records were sent for manual review. If all of these visits were ultimately approved, the percentage of MCO approvals would increase from the reported 53% to 82%. Only if none of the patients in this category were approved by the MCO would the difference in approval rate be as high as reported.

The authors acknowledge that nurse triage protocols may not be effective in properly identifying patients by the level of urgency. Brillman et al21 have demonstrated a high degree of inconsistency among trained nurses and physicians in the prospective assessment of the timeliness and appropriateness of emergency care. Others may question the validity of category 1 and 2 patients who were in the emergency/urgent categories. For example, the nurse triage criteria assign a patient to category 1 —immediate care if the patient had a condition that created a nuisance in the lobby. Interevaluator agreement between 2 physicians who evaluated the same sample of charts is reported at 80%, and the authors note that the physician reviewers could have been biased by knowledge of the final diagnosis.

Despite limitations, the study provides some interesting findings. Among nurse-triaged category 1 and 2 patients who were deemed by the methods used to be emergency/urgent, the MCO paid only 56% of claims, denying 15% and sending 29% for manual review. Ironically, among the 387 patients deemed not to meet the prudent layperson standard by the reviewing emergency physicians, the MCO plan paid 33% of these patient claims, denied 33%, and sent the remaining one third for manual review. Therefore, use of the prudent layperson criteria instead of a diagnosis-based method not only resulted in a different proportion of approved claims, but a different distribution of patients who would have their claims covered by managed care. In this limited study, review by an emergency physician would have resulted in the nonpayment for services by the MCO for at least 128 patients whose services would have been paid under the diagnosis-based MCO system.

The method used—manual review of charts by emergency physicians to determine compliance with the prudent layperson standard—is very labor-intensive and would be problematic from a cost and efficiency perspective on an ongoing basis. Another important issue would be the conflict in roles of emergency physicians under such circumstances. Traditionally, the essential role of a physician is to serve as an unbiased advocate for patients. As noted, the method used in this study would result in emergency physicians making determinations that could deny payment for services by a managed care plan among patients who would have had such services covered under the non–prudent layperson method.

In many ways, the prudent layperson approach, which certified nearly 80% of patients in this study, would return emergency medicine to the golden period when the patient defined an emergency by showing up at the door of an ED.

Many emergency physicians may interpret this study as proof that the prudent layperson method works with regard to resolution of the problems of retrospective denial of reimbursement for emergency services by MOCs. Although such an interpretation is appealing from the perspective of emergency physicians, other sectors of the health care system are unlikely to reach the same conclusions as the authors. From a health policy perspective, the real value of this study is that it clearly demonstrates that the prudent layperson approach, although arguably a start in the right direction, is seriously flawed as a reliable method of assigning patient levels of urgency in the ED.

The authors report an interevaluator agreement rate between 2 emergency physicians who evaluated the same sample of charts as 80%. Although this is pretty good, put another way, 2 physicians from the same institution could not accurately agree on 1 patient in 5 with regard to meeting the prudent layperson standard. How much greater would be the disagreement among evaluators who represent the MCO plan? What if nonphysicians were used to make the determination of compliance with the standard? As long as the validation process of who qualifies under the prudent layperson definition is based on subjective criteria, there will always be legitimate and intense dispute over whose definition is correct. As in the past, emergency physicians will push for inclusive criteria, while managed care organizations will promote exclusive standards.

In summary, the prudent layperson definition can serve as a method of certifying a level of urgency sufficient to warrant emergency services. Because the method is inherently based on subjective criteria, however, the widespread implementation of such a plan would likely be met with intense opposition, with key players promoting their own subjective interpretation of the certification criteria. To be an effective and acceptable policy mechanism, the prudent layperson definition must be expanded in practical terms to include a more accurate and verifiable group of criteria. And this requirement for objectivity rather than subjectivity is the crux of the problem for policymakers, patients, insurance companies, and emergency physicians. The trick, of course, is trying to get agreement among disparate and conflicting groups of stakeholders as to the correct set of explicit and objective criteria.

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References 

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☆ Address for reprints: Robert M. Williams MD, DrPH, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029; 231-938-2494, fax 231-938-0364; E-mail: erdoctor@traverse.com .

PII: S0196-0644(00)34568-1

doi:10.1067/mem.2000.109212

Refers to article:

  • Results of Provider Self-Adjudication Using the Prudent Layperson Standard Compared With the Managed Care Organization’s Emergency Department Claim Review Process

    Robert Shesser, Keith Holtermann, Jeff Smith, Joseph Braun
    Annals of Emergency Medicine September 2000 (Vol. 36, Issue 3, Pages 212-218)

Annals of Emergency Medicine
Volume 36, Issue 3 , Pages 238-240, September 2000

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