State limiting ER visits

MEDICAID: After 3 trips to ERs in a year, some 700 conditions now won’t be covered

September 26, 2011 

STEVE BLOOM — Staff photographer

  • EMERGENCY ROOM REGULARS

    In the year ending June 30, 2010:

    • Number of Medicaid patients making more than three trips to emergency rooms for what the state considers nonemergencies: 11,140

    • ER visits made by those patients beyond their first three trips: 46,537

    • Kids who made more than three ER trips for nonemergencies: 1,007

    Source: Washington state’s Health Care Authority

State government is about to start refusing to pay for repeat visitors to emergency rooms whose conditions don’t truly rise to the level of emergencies.

The trouble is all in how you define an emergency.

Starting Saturday, Medicaid won’t pay for more than three ER visits in a year for a patient’s nonemergency conditions as defined by the state.

A list of more than 700 diagnoses put into that category has drawn fire from hospitals and doctors’ groups over inclusions whose symptoms seem awfully similar to emergencies:

 • Shortness of breath and some types of asthma attacks.

 • Kidney stones.

 • Hypoglycemic coma.

 • Nonspecific chest pain or abdominal pain.

 • Nonspecific congestive heart failure.

If a condition is left unspecified, that means it turned out to not be connected to a more dangerous ailment such as a heart attack or stroke. But doctors say that result can’t be known until patients are treated.

“Do (patients) know the difference necessarily between heartburn, heart attack, a blood clot in my lungs and a sore rib?” asked Dr. Stephen Anderson, president of the American College of Emergency Physicians’ state chapter. “These people shouldn’t be sitting at home trying to self-diagnose.

“My worry is, the message we’re going to be sending is the wrong message, which is, you should not be coming to the emergency department; you should be staying away,” said the Auburn Regional Medical Center doctor.

The state Health Care Authority sent letters to patients on Medicaid, the federal-state health insurance for the poor, warning them the government wouldn’t pay for their nonemergency treatment after three visits.

The agency is trying to save an estimated $72 million in federal and state Medicaid spending, as directed by state lawmakers who tried this spring to crack down on emergency room misuse.

Some conditions on the nonemergency list, such as sunburns and blisters, are not controversial. But others are clear emergencies, says Anderson’s group and other doctors and hospital groups putting pressure on the state to change course.

The emergency doctors’ group says refusing to pay for those conditions opens the state to a costly lawsuit.

FREQUENT USE

Many patients who are poor make the emergency room their first stop.

More than 46,000 times in fiscal year 2010, Washington ERs treated the conditions listed as nonemergencies for Medicaid patients who already had come in for three, four or even more similar visits that year, state officials say. One person visited 125 times.

That kind of repeated use is far from the norm – just 3 percent of Medicaid ER patients seek emergency care more than three times for those conditions – but when it happens, taxpayers or hospitals foot the bill.

“What we’re talking about here is people that go to the emergency room 10, 20, 30 times,” said Dr. Jeff Thompson, the state Medicaid program’s chief medical officer. “I do not have to do an (electrocardiogram) every time ... because I know that this is a subjective, ill-defined chest pain.”

He said some 17,000 kinds of true emergencies will continue to be covered, and even for those conditions deemed nonemergencies, there are exceptions made for all kinds of circumstances. Abnormal vital signs or serious risk factors for poor health will be tickets to paid care, as will arriving in an ambulance or with a referral from a primary care doctor.

Thompson said his agency has removed some conditions from the list, but said critical questions about why each diagnosis is on the list miss the larger point.

“I don’t have time to engage people in silly arguments like that,” he said. “What I need is serious people to sit down at the table and work with us, because quite frankly it’s out of control.”

Thompson says Washington can’t afford to pay for emergency rooms to treat chronic conditions and hand out pain medication, a common remedy for frequent users of emergency rooms.

The government is essentially shifting the cost of providing care to frequent users of emergency rooms to hospitals. That will drive up the cost of care, said Cassie Sauer of the Washington State Hospital Association.

Budget writers in the Legislature declared hospitals could simply pass on the costs by billing the patients for their nonemergency visits – but Sauer said state laws on charity care for the poor prevent them from doing that.

Laws also require them to evaluate all patients who come in, and hospitals said they won’t be turning anyone away without treatment.

“We of course are going to see these patients. There’s no question about that,” said Dr. Tony Haftel, associate chief medical officer for Franciscan Health System.

OTHERS TO FOLLOW?

Some doctors worry that insurance companies will follow the state’s lead.

Washington and other states require insurers to pay for what a reasonable layman would think is an emergency, said Dr. Nathaniel Schlicher, associate medical director for the emergency department at St. Joseph Medical Center in Tacoma. He said the state is violating that standard and may give private insurers cover to refuse care – for any number of emergency room visits.

“This is potentially catastrophic nationally,” Schlicher said.

Thompson said it’s up to private insurers whether to mirror the state, but Medicaid is different in that the state can’t charge patients a deductible or copay. Because patients don’t pay a share of treatment, there’s no financial incentive for them to avoid using the ER.

Jordan Schrader: 360-786-1826
jordan.schrader@thenewstribune.com
blog.thenewstribune.com/politics
Twitter:@Jordan_Schrader

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