Adverse outcomes of managed care gatekeeping

Area of Science:

• Health Services Research
• Patient Safety
• Emergency Medicine

Background:

• Managed care organizations (MCOs) often implement preauthorization requirements for emergency department (ED) care, a practice known as medical gatekeeping.
• This process involves MCOs requiring ED staff to obtain approval from on-call personnel before providing treatment, with reimbursement contingent on this authorization.

Purpose of the Study:

• To investigate the association between telephone preauthorization for emergency department care by MCOs and adverse patient outcomes.
• To identify the types and frequency of adverse events, increased risks, and near misses associated with MCO gatekeeping.

Main Methods:

• A structured review of case reports from 1994-1995 concerning adverse outcomes linked to managed care gatekeeping was conducted.
• Eligible cases involved MCO ED payment denials, which were retrospectively classified by two physicians into categories: adverse outcome, increased risk, near miss, or none.

Main Results:

• Out of 143 reviewed cases, 29 involved MCO ED payment denials.
• Among these, 14% (4 patients) experienced adverse outcomes, 14% (4 patients) were placed at increased risk, and 72% (21 patients) represented near misses.
• Adverse outcomes included respiratory failure, hypovolemic syncope, hypovolemic arrest, and prolonged postoperative course. Near misses encompassed a wide range of conditions, from ectopic pregnancy to unstable angina.

Conclusions:

• The study confirms that adverse outcomes can occur as a result of MCO gatekeeping practices.
• While the frequency of these events remains uncertain, the findings highlight potential safety concerns.
• Further investigation into the safety and implications of MCO gatekeeping in emergency care is warranted.