Advocacy
Talking Points: Limiting ED Visits for Medicaid Patients
(09/09/11) Despite clear budgetary language that the Health Care Authority (HCA) “shall collaborate closely with the Washington state hospital and medical associations in identification of the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered", this has not occurred. The task force repeatedly met and attempted to produce a collaborative diagnostic list or agree to a non-emergent list that ensures patient safety, but the earnest efforts of these groups has been met without collaboration by the state. The HCA’s diagnosis list includes conditions that are emergent, including chest pain, abdominal pain, asthma, miscarriage, kidney stones and congestive heart failure, among the over 700 diagnoses on the list.
This poorly designed policy could result in severely jeopardizing the health of Medicaid patients who need emergency care. People who receive Medicaid coverage are among the most vulnerable in our state - pregnant women, children, people with disabilities, people living with mental illnesses, and people with very limited resources. There are ways to reduce the number of emergency room visits that will save the state money – but the approach being pursued saves money indiscriminately while jeopardizing patient care.
We hope to be able to collaborate with the state in a meaningful way that finds savings without arbitrarily limiting access to necessary medical care for those covered under the Medicaid program.
While the budget measure represents an “easy” and “quick” fix, the consequences are potentially devastating to patients, families, the Medicaid system and the safety net of the Emergency Department. The real costs to this budget measure include:
Sicker Patients, More Admissions
Patients will decide against seeking needed emergency care out of concern for using one of their three allowable visits. This could worsen their health and leave conditions untreated; which is particularly risky for babies, children and people with chronic conditions. The end result of this, of course, will be the need for prolonged and more intensive care, which will not only put people’s health at risk, but increase the overall costs of caring for these patients.
Harm to the Working Poor
Medicaid patients with serious, multiple, or chronic health care conditions, and who often have the greatest need for emergency care, will be placed at greatest risk. Shifting the burden of emergency care from the state health plan to the working poor who already suffer from a lack of access, challenges with employers and excused absences, and limited finances is unjust. We can do better for the citizens of Washington.
Jeopardizing the Safety Net of the Emergency Department
Providers of emergency care are required by federal law to screen and, as necessary, work to stabilize every patient that seeks emergency care. Limiting the number of emergency department visits that Medicaid will pay for does not eliminate the requirement that Medicaid patients must still be seen, no matter how many ED visits they’ve made.
Problems associated with uncompensated and undercompensated care are exacerbating significant financial burdens on physicians and emergency care providers as well as contributing to emergency departments closings across the country. We have lost 1 in 12 emergency departments in the last decade and more are closing every day.
Costly Litigation
There is the real, and costly, possibility of litigation against the state for implementing a plan that is on its face a contradiction with state and federal law. The prudent layperson standard in state and federal law prohibits this type of retrospective denial. Additionally, the plain language of the statutory requirements for collaboration and a list of non-emergent diagnoses have been ignored. These laws were put in place to protect patients from these types of capricious and unsafe actions.
Costly Implementation
To establish a program to review, deny, and deal with an appeals process is an additional administrative cost that provides no patient benefit or actual medical care. We need to shift towards a program that is sustainable and improves quality of care without arbitrarily capping the number of allowable visits.
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