Washington State Gov. Christine Gregoire has blocked a plan by the state's Medicaid program to stop paying for emergency visits for all conditions deemed “nonemergency.” Set to go into effect on April 1 had the governor not intervened, the plan would have suspended payment for ED visits for some 500 diagnoses for adults and children, including abdominal pain, some brain infections, and many types of trauma.
Marty Brown, Gov. Gregoire's budget director, told the media that the governor had suspended the plan at the last minute in light of growing support in the state legislature for an alternative plan proposed originally by emergency physicians and hospitals sponsored by Rep. Eileen Cody.
The original Medicaid proposal “sends the wrong message to patients: that they are not wanted for emergencies in the emergency department,” said Stephen Anderson, MD, the president of the Washington chapter of the American College of Emergency Physicians. “Their list included things like burns to children. If you fall down and your ankle is twice the size of normal, and you can't walk on it, and you come to the ER, if I x-ray it and it's broken, they'll pay.
“But under this proposal, if it turned out not to be broken, they wouldn't pay. A ‘foreign body in the hand‘ is on the list so if you shoot a nail gun through your hand, it's not covered, and I'm supposed to tell you on Friday to wait and see your primary care doctor on Monday.”
By law, emergency physicians still must screen all patients so the savings under the plan would have been minimal, said David Seaberg, MD, the president of national ACEP. “Say your child has an earache and you want to make sure it's not an emergency. We do a screening exam and diagnose an ear infection. It takes just another minute for me to write a prescription for an antibiotic and get you some relief. It makes no sense for me to say, ‘Pay $400 now or get an appointment with your primary care doctor,’ when the patient will then be in more pain and his parent will have to miss work to take him to the doctor. Why not just take care of him?”
Dr. Seaberg acknowledged that Washington's looming state budget deficit — now put at $1.2 billion — requires cost-cutting measures and that the state is far from alone in its need for cutbacks. “Over 70 percent of state Medicaid programs are struggling, and we do need to try to reduce costs,” he said. “But ED care is only two percent of all health care costs. This isn't a very big savings for the risk they are taking with people's health.”
The proposal struck at the core of the prudent layperson standard for determining the need to visit the ED, Dr. Anderson said. “If a prudent person believes he has an emergency, he has a right to go and be cared for in the emergency department and not worry about payment being denied. But it's not enough for us as ER physicians and hospitals to say no, this is bad policy. You have to bring a real alternative to the table, because it's real money we don't have to spend right now.”
That's why the Washington chapter of the ACEP helped to develop the proposal that is now being considered by the legislature:
- Improved coordination of care. The state has already identified a list of 4,000 to 5,000 “patients requiring coordination,” people who are high users of the ED for issues ranging from psychiatric problems to drug and alcohol abuse to severe chronic illness. “We want to help coordinate those patients' care by assuring that they have access to primary care for their problems so that we're not doing unneeded interventions in the ED,” said Dr. Anderson. The system would cost $10,000 to $15,000 per hospital to set up, and he said he hoped a federal grant could defray the cost. The system ultimately could save the state $10–15 million annually, he said.
- Strict guidelines for opiate prescription for chronic pain. The components of this policy are already in place, Dr. Anderson said. “There's a new state program that makes every restricted prescription filled in the state available online to authorized prescribers. I can find out immediately if a patient has been getting narcotics at other places recently. The program has been in place for six months and already decreased ED utilization, although the data won't be published until the end of this year.”
- Improved use of generic indications. “We in the ED live off the $4 prescription pharmacy list because we have to be very judicious in our prescriptions as most of our clients are uninsured and have no resources,” Dr. Anderson said. So emergency physicians offered to “carry the banner” to convince all physicians in the state to adopt a Medicaid-style generic formulary to help cut costs.
Washington is at the “tip of the spear” for other states looking to make cuts from their cash-strapped budgets, Dr. Anderson said. Had the proposal gone through — and it's not entirely dead yet, just on hold pending the legislature's action — it could have opened the floodgates for similar policies elsewhere.
That worries Gabriel Wilson, MD, the associate medical director of the emergency department at St. Luke's-Roosevelt Hospital Center in New York City. “I think more enlightened legislatures would realize this isn't the way to go. I don't think it would ever happen here in New York. But it could happen elsewhere. And the fact is these policies aren't going to change things.”
He pointed to a perspective published in the June 2011 New England Journal of Medicine by Richard Rieselbach, MD, and Arthur Kellermann, MD, that found that the percentage of people discharged when they come to seek care in the ED has remained steady at 84 percent over the past 50 years. (See FastLinks.)
“No matter what's mandated, people will come as they need to be seen,” Dr. Wilson said. “So the costs will be shifted: instead of the government paying for medical care, they're going to force the hospital to pay. The hospitals least affected by such policies will be the ones who see the fewest Medicaid patients, those who have insurance that reimburses well. But the safety net hospitals, those who tend to provide care in the inner city and have the least financial cushion, will have to subsidize even more care. And that could push them over the cliff into insolvency.”
- Visit the Washington ACEP website at www.washingtonacep.org for a sample letter to send to legislators, talking points for physicians, and other resources.
- Read the free full-text article, “A Model Health Care Delivery System for Medicaid,” by Rieselbach and Kellermann from the New England Journal of Medicine at http://bit.ly/I50WLu.
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