State Medicaid program to stop paying for unneeded ER visits
Starting April 1, Medicaid will no longer pay for such visits, even when patients or parents have reason to believe they're having an emergency. Hospitals and doctors are pressing lawmakers to undo the policy.
Seattle Times health reporter
Intent on cutting state budget health-care costs, Medicaid officials say the program will no longer pay for any medically unnecessary emergency-room visits, even when patients or parents have reason to believe they're having an emergency.
The rules — arguably more drastic than an earlier proposal to limit Medicaid patients to three visits per year for nonemergency conditions — would block payment for ER visits for about 500 different conditions.
They would apply to all adults and children on Medicaid, with no exceptions, such as someone being brought in by ambulance or from a nursing home, or when patients have neurological symptoms or unstable vital signs.
The new rules are to begin April 1, but a statewide group of emergency doctors, backed by the Washington State Medical Association and the Washington State Hospital Association, are pressing lawmakers to stop the plan, arguing it would shift costs to hospitals and ER doctors and deny care to people with real emergencies.
"The simple fact is that quality patient care does not happen when bureaucrats stand between the physician and patient to dictate what is considered an emergency and what is not," Dr. Stephen Anderson, president of the Washington Chapter of the American College of Emergency Physicians, said in a statement released Tuesday. "It's just not safe. And it's just not right."
The doctors and hospitals have proposed an alternative they say would reduce costs and protect quality care, but the state has dismissed it as having no specific plan or timetable for how it would be accomplished.
Dr. Jeff Thompson, chief medical officer for Washington's Medicaid program, said the state is committed to paying for medically necessary care. But many times, he said, patients go to ERs when they would get better, and less expensive, care in a primary-care "medical home."
"The ER cannot be the medical home of the 21st century," he said. "We will not pay for diaper rash treated in the emergency room."
Currently, there is "tremendous overuse and abuse" of emergency rooms, Thompson said — amounting to at least $21 million a year.
Some patients show up as many as 120 times a year for costs of $20,000 to $25,000, he said, but until now, most ER doctors and hospitals have done little to deter them because the state paid the bills.
"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," Thompson said.
"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.
Under the new rules, ER services not paid by Medicaid wouldn't be billed to the patient, leaving the doctor or hospital on the hook.
The skirmish between Medicaid and the doctors and hospitals is the latest in a long-running battle with origins in the state's budget crisis.
Early last year, state Medicaid officials, eager to save as much as $76 million in the biennium, proposed a three-visit limit for any of about 700 conditions they said could be treated by a primary-care doctor.
The doctors and hospitals objected, noting the list contained not only obviously nonemergency conditions such as diaper rash or acne, but hypoglycemic coma, asthma attacks and chest pain — conditions that might indeed be emergencies.
In a lawsuit filed in Thurston County Superior Court last year, emergency physicians argued the state's process was arbitrary and capricious.
In November, a judge ruled that the state had not followed a proper rule-making process, which would require public hearings.
The state pared the list, removing some of the most hotly contested conditions such as chest pain. But instead of going through the process to change the rule, officials sought guidance late last year from federal authorities, who provide part of the Medicaid funding.
According to Medicaid's Thompson, they said the state could move to a "medically necessary" standard without having to change its rules or go through a hearing process.
Each side has accused the other of not collaborating to reach a mutually acceptable solution.
Thompson said he's long offered to provide hospitals with a list of about 4,000 frequent ER users — primarily patients seeking narcotics. Out of about 1.2 million Medicaid patients in the state, these are the ones who use ERs far too much, running up total bills of about $7 million per year — a fair hunk of the $21 million a year Thompson said he needs to shrink his budget.
But until the state said it wouldn't pay, hospitals weren't interested in that list, said Thompson, who maintains that hospitals and ER doctors must do more to help patients find appropriate primary care.
Dr. Nathan Schlicher, an emergency physician in Tacoma and legislative chairman for the emergency-physicians state chapter, was in Olympia on Tuesday, urging lawmakers to stop the plan.
"The original plan was bad," Schlicher said. "This plan is outrageous."
For Medicaid patients, Schlicher said, the plan suggests that even before heading to the ER, they should know what their ultimate diagnosis will be.
"If we don't know without an X-ray or CT scan, how can they know it?"
For doctors, the plan could place them in legal jeopardy, Schlicher said.
If they turn patients away, "it's not good care and it doesn't meet the legal standard," he said. "I can't tell any provider to commit medical malpractice, no matter how much the state wants us to do that."
But if the doctors provide care for any of the conditions on the state's list, such as an ear infection or a bladder infection, they would have to do it for free.
Schlicher said he and other doctors have offered about 200 conditions they agree are most often not emergencies, but want the state to allow exceptions for a patient's condition — such as when their vital signs are unstable or they have neurological symptoms.
The doctors have offered what they call a physician-developed plan they say would reduce narcotic-seeking behavior, coordinate ER visits with primary-care access, spearhead a "generics first" effort, develop a statewide preferred-drug list, and institute a case-management system for frequent users.
Schlicher said if the state's current plan is implemented, it would be the most restrictive Medicaid ER policy in the nation.
Other states have tried to limit visits, he said, but later abandoned the programs or used a much shorter list of nonemergency conditions.
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org. On Twitter @costrom.
Information in this article, originally published Feb. 7, 2012, was corrected Feb. 9, 2012. In a previous version of this story, Medicaid officials gave an incorrect figure for the amount they expect to save in state funds. Medicaid expects to save $21 million in state funds over 15 months, beginning April 1.