Last month, I rushed to a nearby hospital for emergency care after experiencing pelvic pain and abnormal bleeding. Because I had a history of complications from ovarian cysts, my physician recommended I go straight to the emergency department. While waiting to be seen, I read a news report that my insurance provider, UnitedHealthcare, was considering a new policy that would deny payment for emergency department visits that it retrospectively deemed “unnecessary.”
When I saw that ovarian cysts were a condition that might be refused payment under United’s proposed policy (the only one mentioned other than pink eye), I had to read the sentence twice, then I read it aloud to my partner. I was shocked that cysts were cited as a condition that might not warrant an emergency department visit, and not just because I’m an ethicist who works in medicine.
I know firsthand how devastating an ovarian cyst can be. Ten years ago, one nearly derailed my wedding — and definitely derailed my honeymoon — when it twisted my right ovary.
The new policy, if enacted, would discourage women from seeking attention for abnormal pain. Women already face hurdles in having their symptoms taken seriously, whether due to undertreatment of their pain, misdiagnosis of their symptoms, or underreporting of their conditions based on male prototypes. The risks are amplified for women of color, queer women, and trans women, for whom medical misogyny intersects with racism, homophobia, and transphobia.
The policy would also place women at risk of complications such as infertility. Ovarian cysts are not rare, with significant cysts likely in 8% of premenopausal women and 14% to 18% of postmenopausal women. Although most are benign, a large benign cyst can still cause problems — like damaging or destroying an ovary — and may need to be surgically removed.
A comprehensive assessment usually begins with an ultrasound. While these can often be scheduled through a physician’s office, an emergency department may be a better bet due to a person’s history or the sudden onset of pain.
My history with ovarian cysts began in 2011. I was in my hometown during the weeks before my wedding, so I took advantage of the trip to see my family physician, who had been treating me since grade school. When I mentioned I had been having abdominal pain, she scheduled me for an ultrasound.
During the scan, the radiologist pursed her lips and began clicking the mouse rapidly, saving shots of the screen. I soon learned that she had been the first person to notice that an ovarian cyst, the size of a grapefruit (or a softball, depending on who I asked) was weighing down my right ovary and twisting it, cutting off blood flow and killing it.
I would have been sent for immediate surgery had my wedding not been in five days, and surgery would mean calling it off. My physician let me postpone the surgery to attend my wedding, provided I avoided strenuous activity and went immediately to an emergency department if I developed severe abdominal pain or a fever, signs that the cyst had burst and I was at risk of the serious blood infection known as sepsis.
I made it through the wedding, trying not to dance too hard and to be mindful of my temperature. Two days later, instead of being on a flight to Europe for my honeymoon, I was getting prepped for surgery to remove the cyst along with my dead right ovary.
Now, almost exactly 10 years later, I was back in the emergency department for symptoms consistent with another ovarian cyst. As soon as the attending physician heard my medical history, he ordered an emergency ultrasound. The radiology technician let me know that, sure enough, I had a large cyst on my remaining ovary: 5.1 centimeters, about the size of a lime, just at the cusp of when surgical removal is often recommended to avoid complications such as torsion, a potentially harmful twisting of the ovary.
That put me in a holding pattern. An ultrasound six weeks later would determine if the cyst had stayed the same size, or even better, had shrunk. If it was growing, and twisted my left ovary, both would need to be removed and I would then enter menopause at age 34. I’m currently five weeks out, waiting for the next ultrasound.
I have found myself wondering what I would have done if United had changed its policy before my second bout of severe abdominal pain. There’s a high likelihood I would have avoided — or at least delayed — the emergency department visit so as not to risk a high medical bill.
In 2011, I didn’t go to the emergency department when a cyst was twisting my right ovary. We were graduate students living below the poverty line in student housing to save money — the bar for visiting the emergency department then was much higher than it is now.
Instead, I sought non-urgent medical attention from my OB-GYN at the time, who told me the pain was likely just menstrual cramps and not to worry. If I had gone to the emergency department when a strong pain in my pelvis forced me to sit down with a grimace that my partner remembers to this day, I might have two ovaries now instead of one, and not have to worry about menopause in my mid-30s.
United might say that this is exactly how its policy is supposed to work, since I did not require emergency surgery last month, and the policy would have deterred me from going to the emergency department. This is faulty logic. The symptoms of an ovarian cyst resemble ovarian cancer, appendicitis, diverticulitis, and an infected gall bladder. Sometimes it might just be menstrual pain, but who’s to know until it’s checked out?
When people do seek emergency care, even the insured can be overcharged. A 21-year-old Stanford student was recently billed more than $700 for the mere act of a nurse pushing medication through her intravenous line while she was in an emergency department after her ovarian cyst ruptured (her insurer, Anthem Blue Cross, is considering a similar policy to United).
The student, Claire Lang-Ree, described enduring the pain to finish a college chemistry quiz. I can relate to that. Yet she judged that the pain warranted a trip to the emergency department, a decision I wish I had made 10 years ago.
Letting insurance companies judge retrospectively that emergency care is not medically required creates a dangerous system in which patients must diagnose themselves and then live in fear they’re wrong so they won’t be faced with an exorbitant bill by their insurance provider.
I can understand insurers’ desire to reduce the costs associated with unnecessary emergency visits. I’ve faced emergency department overuse firsthand in my work as a clinical ethicist. But the source of the problem is not individual patients’ judgments of their medical conditions. It is inadequate access to quality, routine medical care forcing some people to rely for that on their local emergency department. The solution is systemic and includes expansion and accessibility of preventive and primary care services.
Inconsistent pricing is also a problem — the Stanford student’s total bill amounted to a $18,735.03, including two of those $700 IV pushes.
Any insurer trying to reduce the cost of emergency care should recognize that making patients the arbiters of their own medical state is not an ethical route to this goal. If they don’t, institutions like mine that contract with them for the benefit of their employees should find insurance providers who protect their subscribers’ interests rather than asking them to judge their need for care based on expertise they cannot be expected to possess.
Laura Specker Sullivan is an assistant professor of philosophy at Fordham University and the former director of ethics at the Medical University of South Carolina.