Sick at home with coronavirus, Laurie Wilson became worried about her intensifying headaches and nausea so she drove herself to the emergency room at the main hospital in Gainesville.
Inside Northeast Georgia Medical Center, she said she found herself in a scene resembling a war movie. About 50 to 60 people were packed into the ER waiting room, some complaining and moaning in pain, children screaming and crying.
One child threw up. Across from her, a woman sat curled up in a waiting room chair, leaning her head against the clear divider between seats.
“It’s insane,” Wilson said in texts to The Atlanta Journal-Constitution during what became a six-hour wait before she finally saw a physician assistant. “Some people have been in here for days because there are no beds.”
As the pandemic surges, scenes such as the one at the Gainesville hospital are playing out in hospital emergency rooms throughout the state. Desperate for relief, administrators at the Gainesville hospital turned to Georgia Insurance Commissioner John King for help.
King has devised a plan to help relieve overrun emergency rooms, hoping to avert a public health disaster when another expected surge of coronavirus infections hits after Christmas. That plan involves King exerting authority he doesn’t really have over health insurance companies, and their complying for the sake of the common good.
The plan, though, comes with risks: Some patients could wind up with thousands of dollars of medical bills they weren’t expecting.
Hospital leaders told King that their capacity problem could be lessened if they could get help moving out of the hospital patients who are ready to be discharged. Health insurance companies are holding up the process by taking days or a week to approve transfers to next-level care, such as nursing homes, rehabilitation centers or home-based care, according to Dr. Clifton Hastings, chief of Northeast Georgia Medical Center’s medical staff.
The day after King visited the Gainesville hospital to see conditions for himself, he issued a directive for all licensed Georgia health insurers to suspend pre-authorization requirements for post-acute treatments for 60 days.
“Under normal circumstances it may take up to 7 days for hospitals to receive authorization to move a patient to the next level of care,” the commissioner’s Dec. 3 directive says. “This puts the patients at risk and hinders a hospital’s ability to efficiently discharge patients to make space available for COVID-19 and other patients in need of care.
“Accordingly, the Department requests that all issuers respond to requests to discharge patients to lower levels of care within 24 hours. This includes requests submitted on Fridays.”
Many insurers are on board.
However, some industry experts point out that by fast-tracking a process designed to route recovering patients to facilities covered by their insurance plans, the directive could lead to surprise bills.
A new law against surprise billing, approved by state lawmakers this year, takes effect Jan. 1. One of the exceptions in the law, though involves non-emergency hospital charges. Patients in those situations must still do their homework and find out what facilities are in their insurance network.
In a non-emergency such as a discharge to post-acute care, it hasn’t been established how hospitals must disclose any out-of-network costs to patients ahead of time, said Laura Colbert, executive director of Georgians for a Healthy Future.
She fears some patients won’t be fully protected with the insurance commissioner’s directive if they’re moved out of network.
“Is it just a piece of paper in a full stack of papers that you sign when you’re filling out all the intake forms?” she said. “Or is it what we would like to see, you only see this paper as a standalone piece if you are being referred out of network at that time, and with a very clear cost estimate that is line by line?”
Another hitch: The insurance commissioner’s directive also says that insurers may review post-acute placements for medical necessity after such moves, allowing the companies to refuse coverage.
“If they could retrospectively say they weren’t skilled nursing appropriate and deny payment for that, that is very concerning,” said Neil Pruitt, chairman and CEO of Atlanta-based PruittHealth, one of the largest senior care companies in the Southeast. “Obviously, the nursing home industry is in dire financial straits right now. The last thing we can do is provide free care, unfortunately.”
King’s office, though, says the directive only asks insurance companies to move faster, not to approve sending patients into care that they wouldn’t approve ordinarily.
Credit: Jenni Girtman for the AJC
Credit: Jenni Girtman for the AJC
The unending surge
Commissioner King told the AJC that only a few insurance companies have balked, pointing out to him that his office doesn’t have any authority over federal insurance programs, such as Medicare.
“So I’m being a little bit more forceful with them,” King said. “I was like, ‘Look, do you really want to push back on what we’re asking you to do? We understand that your profits have been pretty good this year, through this pandemic. You don’t want me to look at other options that I might have in my tool kit to get you to help us out on this.’”
So far, many insurance companies say they will do what the commissioner has requested as soon as possible.
In a written statement, Anthem Blue Cross and Blue Shield’s Georgia president Pamela Stahl said, “We are happy to comply with the DOI Commissioner King’s directive. As the state’s largest insurance company, we are committed to ensuring the health and wellbeing of all Georgians, and working with our provider partners, all of whom are feeling the effects of this national pandemic.”
A representative for health insurance companies, Jesse Weathington, told the AJC “we’re committed to not being part of the problem here.”
But it’s unclear how long it will take for all companies to ramp up to 24-hour turnarounds, said Weathington, president and CEO of the Georgia Association of Health Plans. Sometimes discharge requests hit snags when companies don’t receive complete information. They’ll also have added expenses to contend with from paying staffers to work through weekends, he said.
Georgia may not have much time left to fix the problem, as the virus continues to tear through communities.
Data from the U.S. Department of Health and Human Services for the week ending Dec. 10 showed hospitals statewide at 86% capacity for intensive care beds. Grady Memorial, Wellstar Douglas in Douglasville and Tanner Medical in Villa Rica were all completely out. Only two beds were left at Piedmont Columbus Regional and Emory Decatur, and only one was left at both Wellstar Cobb in Austell and Tanner Medical in Carrollton, according to the federal data.
In the middle of last week, the Georgia Department of Public Health reported the hospital regions surrounding Gainesville, Marietta and Carrollton all had more than 90% of their inpatient beds full, and the districts surrounding Augusta, Milledgeville and Albany had more than 90% of their ICU beds filled. The Georgia Coordinating Center marked 28 hospitals overcrowded on Thursday, 15 of them “severe.”
On Thursday Augusta’s University Hospital set another single-day record for COVID-19 hospitalizations, with 118. That topped Wednesday’s record of 110.
Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com
Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com
Beds tied up for days
Hospital officials who spoke to the AJC last week say if insurance companies follow the state directive, it could ease the strain.
Hastings, chief of Northeast Georgia Medical Center’s medical staff, estimated the hospital system could open up to 25 beds per day out of the 700-plus beds systemwide.
The way the process works now, he said when a hospital wants to move a patient to a rehab facility or long-term care, it submits paperwork to the insurance company, and it may take two to three days to get a response.
If the answer is no and more information is needed, the hospital provides that, and if it’s a Friday, the request may sit all weekend with no response until Monday or Tuesday.
Hastings described one 48-year-old, who had heart surgery the weekend before Thanksgiving, taking two weeks to be moved to a nursing home, where he could go into rehab and receive intravenous antibiotics.
“It’s a state and nationwide problem,” Hastings said. “So when we look at capacity issues, if we could solve that, it would really make a huge difference from my perspective.”
Thomas Worthy, vice president of government and external affairs for Piedmont Healthcare, said slow-moving insurance providers have always been an issue for hospitals, but the problem has been exacerbated by COVID-19. He estimated that one-day turnarounds could free up 75 beds a day among the system’s 2,500-bed system with 11 hospitals.
On Monday, West Georgia’s Tanner Health System had 47 patients waiting for beds. Case Management Director Tammy Owenby said she hadn’t seen much impact yet from the Dec. 3 directive, which could free a few beds a day, if any.
Those prospects improved, though, after she received notice from both United Healthcare and Humana that they would suspend pre-authorization requirements into January. Now, she said she would expect another five to six beds to open per day.
“That’s where the real holdup is, with the Medicare Advantage plans,” Owenby said. “They have that sicker population. They have the elderly population. So that’s what really could impact.”
Georgia Sen. Butch Miller, R-Gainesville, who set up the meeting between Insurance Commissioner King and Gainesville hospital officials, said he’ll be watching how the directive plays out. If need be, he said he could propose legislation to fix the problem.
“Healthcare providers are working incredible hours during this state of emergency,” Miller said. “And they don’t close at 5 o’clock on a Friday afternoon and open up on Monday morning. And the industries that support them should not close at 5 o’clock in the afternoon and open up on Monday morning.”