Lawmakers last year called for reducing poor patients’ use of emergency rooms to save Medicaid $72 million, but state officials’ first try at a three-visit limit on “nonemergency” visits to the ER was criticized by doctors and hospitals and struck down by a judge over procedural flaws.
The state now has a new plan with a stricter limit: Medicaid will cover zero ER visits if treatment in an emergency room is “not medically necessary” for a health condition.
The state Health Care Authority would make that call after reviewing a bill from a doctor or hospital. If the agency refuses to pay, the medical provider would still be on the hook for the costs. There’s no threat that patients will be charged, HCA spokesman Jim Stevenson said.
It would save $21 million a year starting April 1, the HCA estimates — perhaps twice that including federal savings. That’s short of the $72 million cut ($33 million state) by the Legislature.
The federal government allowed the HCA to proceed with the new plan in December and doctors were told about the plan shortly afterward; today ER docs called the plan “outrageous.”
In a press release from doctors’ and hospitals’ groups, Nathaniel Schlicher, associate medical director for the emergency department at St. Joseph Medical Center in Tacoma, said:
Putting a faceless bureaucrat between a patient and physician to determine what is a true emergency is dangerous and sacrifices patient safety.
There are no exceptions or age limits to the policy, and Schlicher said in an interview: “There’s no protection for foster children, the elderly, those that come from nursing homes. … They’ve stripped every patient protection out of this thing. It’s just frightening.”
The HCA said it has removed conditions like “nonspecific chest pain” from a list of more than 700 conditions that weren’t covered under the old rule, culling the list down to about 400 conditions that it now calls “examples” of what won’t be covered — items like diaper rash, said Dr. Jeffery Thompson, state Medicaid’s chief medical officer.
Doctors say someone with a neck strain and ankle sprain that leaves them in a splint and crutches wouldn’t be considered an emergency. The HCA says it would if doctors use the correct billing codes; it plans to revise the list based on doctors’ feedback.
“True emergencies, we will pay for,” Thompson said.
For denials, the agency will focus on people who are on its list of about 4,000 Medicaid patients who it says are known to overuse the emergency room, Thompson said. The agency says at least one frequent flyer visited ERs up to 125 times in 2010 and in one recent case a patient with obsessive-compulsive disorder was seen in an ER twice a day. It hopes to push hospitals to send those people to primary care providers.
“What we’re trying to do is treat the ER docs like every other doctor that we contract with,” Thompson said, saying it’s the only area without limits on care.
Doctors say they are lobbying lawmakers to adopt an alternative plan to lower costs, including:
- Reducing ED visits for narcotic-seeking behavior
- Reducing “unnecessary” ED visits by collaborative use of next-day or same-day visits to primary care and improving access to care
- Creating a “Generics First” initiative spearheaded by physicians to voluntarily develop a statewide drug formulary
- Instituting an extensive case management program to reduce inappropriate ED utilization by frequent users
- Tracking emergency room visits to reduce ED shopping
UPDATED 4:30 p.m. with comments from HCA.