Kaiser investigation imperils county emergency services| Guest column

by Loren Johnson, MD

As reported in the Sounder, the State Office of the Insurance Commissioner announced that Kaiser has decided to withdraw from San Juan County at year’s end and that LifeWise Health Plan will take its place as our sole individual market health insurer. Also, the OIC has investigated Kaiser in response to the county’s complaint of unfair air-ambulance claims denials and concluded that the county’s complaints were “unsubstantiated.”

The investigator reviewed 41 Kaiser-insured air transfer cases, during the six-month period ending March 31, 2019. Kaiser approved 17 of the claims, initially denied 24 and reversed six of the denials at the outset of the investigation. Nonetheless, the OIC cleared Kaiser on the remainder of the denials on grounds that had it complied with its own air-ambulance policies.

Lest readers think that Kaiser has been exonerated, a careful reading of the investigator’s report reveals that Kaiser’s policies were cursory and not applicable to our island setting. Most of the denial cases had serious emergencies that required air transport. There was no independent medical review, and from my reading, as an experienced emergency physician, the OIC’s conclusions were contradictory to the evidence, as cited in the report.

Blanket acceptance of this flawed investigation will be viewed as an open invitation to unfairly deny future air-ambulance claims at the sole discretion of the insurer. This will dissuade patients from calling for lifesaving care, will pit patients against emergency providers and, if allowed to stand, would destroy our community emergency medical services system as we know it.

Instead, we must challenge the OIC with constructive counter-proposals. Michael Edwards, Commission chair of the San Juan County Public Hospital District No. 1, has proposed that our air-transfer policies and documentation standards be reviewed and updated, and that additional resources for ferry transfers and all alternatives for safe EMS transfer should be considered. The planned resignation of Dr. Michael Sullivan, our highly experienced EMS medical policy director, and the need to recruit his replacement adds a note of urgency to these proceedings.

I applaud the County Board of Health for going on record with plans to protest the OIC’s flawed investigation, and for recognizing that we must come together as a community to affirm our support for quality EMS.

Last, but not least, we need to review and comment on LifeWise Health Plan’s equally deficient air-transfer policies, promulgate our own island-appropriate policies and make it clear that we will not allow ourselves to be further victimized by unscrupulous health insurers.

Loren Johnson is a retired emergency physician and resident of San Juan Island.