Johnson L A, Derlet R W
Sutter Davis Hospital, Davis, California, USA.
West J Med. 1996 Feb;164(2):137-42.
To control costs, managed care organizations have begun to restrict the use of hospital emergency departments by their enrollees. They are doing this by educating enrollees, providing better access to 24-hour urgent care, denying preauthorizations for care for some patients who do present to emergency departments, and retrospectively denying payment for certain patients who use emergency services. Changing traditional use of emergency departments has resulted in conflicts between managed care organizations and these departments. Because federal law mandates access to emergency care for all persons, disagreements occur over the precise definition of an emergency medical condition. In addition, conflicts occur over the scope and payment for the medical screening examination required by federal law of persons presenting to an emergency department. Finally, issues arise related to the safety of patients who present to emergency departments and request care but are denied care because the managed care organization does not authorize the visit. Recent legislation in California has attempted to reconcile differences between managed care practices and federal and state laws; however, areas of continued conflict need to be resolved to prevent possible adverse consequences for patients actually needing emergency care.
为控制成本，管理式医疗组织已开始限制其参保人对医院急诊科的使用。他们通过以下方式来做到这一点：对参保人进行教育，提供更好的24小时紧急护理服务，拒绝为一些前往急诊科就诊的患者提供预授权，以及事后拒绝为某些使用急诊服务的患者支付费用。改变急诊科的传统使用方式已导致管理式医疗组织与这些科室之间产生冲突。由于联邦法律规定所有人都可获得急诊护理，因此对于紧急医疗状况的确切定义存在分歧。此外，对于联邦法律要求向急诊科就诊人员提供的医疗筛查检查的范围和费用也存在冲突。最后，出现了与前往急诊科就诊并请求护理但因管理式医疗组织未授权就诊而被拒绝护理的患者的安全相关的问题。加利福尼亚州最近的立法试图调和管理式医疗做法与联邦和州法律之间的差异；然而，仍需解决持续存在冲突的领域，以防止对实际需要急诊护理的患者可能产生的不利后果。
