Friday, February 10, 2012

Washington State Medicaid will no longer pay for “unnecessary” ED visits

By now you must have heard the news that as of April 1, Medicaid in Washington State will no longer reimburse hospitals for care of what Medicaid deems unnecessary ED visits. [The Seattle Times report is here.] The problem, of course, is that many times the perceived lack of necessity can only be determined after the patient has been worked up. Even a patient brought in by ambulance will not be covered if it turns out that his illness is not a true emergency as defined by the rules. And hospitals will not be allowed to bill the patients. The unnecessary visits list includes illnesses like hypoglycemic coma and asthma attacks. Unstable vital signs do not matter if the visit is eventually found to be unnecessary.

Hospitals and ED docs in Washington have vociferously objected to this patently stupid plan but so far the state’s Medicaid boss [a doctor] is standing firm.

In addition to the obvious problem of not knowing whether a patient is sick or not before he is examined, what is an ED doc supposed to do if an ambulance brings in a Medicaid patient with a cold? Should the patient be refused entry into the ED?

That probably would not be wise because of a federal law known as EMTALA [Emergency Medical Treatment and Labor Act]. From the website “EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.”

What happens if EMTALA is violated? “A hospital which negligently violates the statute may be subject to a civil money penalty (i.e., a fine, but without criminal implications) of up to $50,000 per violation. If the hospital has fewer than 100 beds, the maximum penalty is $25,000 per violation.”

Anyone who works in a hospital knows that EDs are being inundated with patients who don’t really have emergencies, but shifting the blame and cost to the hospitals and EDs is not the answer.

Like many issues today, personal responsibility is no longer expected or required. The Medicaid card is the “everything” card. Get one and you’re all set. I worked in a city hospital for several years. The Medicaid patients had absolutely no interest in controlling costs. They knew that if they went to an ED, they had to be examined and treated.

Assuming that there are enough primary care doctors, accountable care organizations or “medical homes” in the State of Washington to accommodate the no longer ED-bound Medicaid population [a factor that apparently no one has brought up], wouldn’t it make more sense to shift the responsibility of deciding whether they should go to an ED to the patients themselves?

But that would require some restrictions on the “everything” card. I doubt that any politician or bureaucrat would have the balls to even suggest, much less implement, such a policy.


Diane said...

Another example of the Government making decisions they are not qualified to make.

Insurance rates will double up again this year. The Middle class will end up paying for the legislations idiocy. The WA politicians continue undermine our healthcare. Growing up in WA it was a different place- we moved back for a couple short years and were flabbergasted that a State that has more PhD's then any other State had decided to throw basic academics and logic out the window. It isn't monopoly money they are handing out. We moved back to Texas, which is flawed but still respects the fact that a Medical Dr knows more about medicine then a Politics Major.

I am sickened that those with a "card" can spend with no personal accountability and you and I are responsible for their wasteful spending spree. Let's try holding the card holder responsible for their own body. That would eliminate a huge chunk of waste.

RobertL39 said...

After reading the Seattle Times piece it seems clear to me that this is a political struggle, to wit: "Each side has accused the other of not collaborating to reach a mutually acceptable solution." The doctors apparently have a proposal, but the article doesn't say what the state found unacceptable about it. A solution is possible but it will take some work and compromise. Since the state has a large hammer and sets the rules, they moved first.

When seeing articles about Medicaid patients please remember to consider what their care alternatives are, because frequently there aren't any. We found our 'unnecessary' ER visits in this population went down dramatically when our Medicaid became locally managed and they were assigned to primary care providers.

And how are the "everything card" holders any different than the wealthy person who's met their deductible and goes to the ER for their sore throat because it's convenient, or demands expensive studies or procedures because they know they're not going to have any out-of-pocket cost? The former comes from your taxes; the latter comes from your insurance premiums. Is that really a meaningful difference? I don't think so. Abusers exist in every group.

Anonymous said...

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER." Do they really think ER physicians want to take care of non-emergent conditions or narcotic seeking patients?! I am yet to meet an ED physician who said thy decided to go into emergency medicine because they wanted to be the after hours family physician. As a medical student, I've spent a decent amount of time in the ED and the physicians at my institution were not happy with the costs of caring for the "frequent flyers". In fact, one of the most commonly asked questions in the ED is "what is so different about X,Y, or Z symptom that you've had for however many days/weeks/months, that made you feel that you had to come into the ED at 3am?" before seeing your PCP. The ED physicians don't turn these people away because they are obligated to treat them, not because they think the ED is the best place for them to be treated.

The extra cost of unnecessary ED visits should be placed on the patient, not physicians and hospitals who are already dealing with the repercussions of an exceedingly litigious society. If a patient does not have a primary care provider and uses the ED for day to day medical issues then the bill should go to that patient. It's not right to ask a hospital to turn a patient away when it has to simultaneously adhere to the EMTALA.

I personally think that a better solution would be to require documentation that a primary care physician was contacted prior to arrival at the ED and the PCP believes that it is medically necessary to get emergency care. That takes the decision making away from the patients and should help filter out the cases of acne that show up in ED. Additionally, ED physicians should have the option to turn away narcotic seeking patients who they've treated before as long as they are referred to a chronic pain specialist who can deal with them during regular business hours.

Skeptical Scalpel said...

Thanks for the comments. Good points all. I did mention that it is not clear that Washington Medicaid patients have alternatives to the ED. Implied in that statement is that if the ED is the only place they can go, then penalizing the hospitals makes no sense.

I agree that insured patients abuse the system too. They also should be made to take responsibility for their own health. For example, I know many private patients who insist on an MRI every time they tweak a knee skiing, when a much cheaper visit to an orthopedic surgeon would have ruled out a significant knee injury.

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