Emergency Department (ED) costs are a significant source of our country’s skyrocketing healthcare costs. The ED is often treated as a clinic by uninsured and insured alike, who either do not want to or cannot visit a primary care provider or who do not have one. ED care is expensive and is not at all set up to treat chronic conditions or provide routine care. It is a less than ideal environment for routine care or care for non urgent issues that could wait until office hours at a primary care provider. There are long waits and all the infectious disease risk of hospitals. There is also little or no mechanism for following up with patients to insure compliance with treatment or to gauge effectiveness of treatment.
Washington State, seeking to both lower costs and encourage use of primary care providers is proposing a 3 visit limit per year to EDs for Medicaid recipients. Starting October 1, Washington State Medicaid will deny payment after the third ED visit for what it deems ‘non urgent’ conditions. Although there are valid reasons to try to limit the use of EDs for routine care, the list of over 700 diagnoses that will be excluded is concerning to hospital and provider groups in the state as well as the American College of Emergency Physicians (ACEP).
Washington State’s Health Care Authority (HCA) states: “Medicaid supports emergency room care for emergencies, but non-emergencies and chronic conditions should be managed by your primary care provider. We want every client to have a primary care provider. Limiting non-emergency use of emergency rooms will support the delivery of care in the most appropriate setting.”
It is a valid concern, but this broad brush approach is not the answer to the undeniable problem of ED over utilization.
The prime concern is that the list of diagnoses was developed by the WA Medicaid office with no input from working providers and includes such conditions as chest pain, abdominal pain, miscarriage and shortness of breath along with more obvious non-emergencies such as diaper rash. In addition, the program will base its judgements on discharge diagnosis rather than presenting symptoms.
For example, a person with crushing chest pain that turns out to be a muscle spasm or heartburn could count as an unnecessary visit because the chest pain turned out to be non-cardiac. A pregnant woman with vaginal bleeding and cramps in the middle of the night – regardless of outcome – is another ‘non-emergency’ and will count against her ED visits and potentially not be paid.
And what of women with complicated pregnancies? Should they ‘wait out’ cramps and bleeding? Even if their provider told them to go to the ED in such a case? People who are brittle diabetics or who have children with poorly controlled asthma? Not all medical conditions are so easy to manage with a primary care provider in a 9-5 office. Especially when people are poor. Children who live in public housing have more difficult to manage asthma due to the conditions in which they live. Should they not utilize an ED in the middle of the night for an exacerbation that cannot be controlled for fear of receiving a huge bill they cannot pay?
Again, in chronically ill patients living in poverty, controlling chronic illness is more complicated. Working poor people often work non traditional hours and cannot get to a provider office with traditional hours. The working poor may also work in physically demanding jobs in terrible conditions that cause or exacerbate chronic and episodically acute conditions. Public housing conditions – old buildings with rodent and roach infestations can worsen respiratory and cardiac conditions in adults and children.
A better solution to this problem would be to take high ED utilizers on a case by case basis and investigate why they use the ED so frequently. Not only would this be a fairer solution, but it would shed light on the reasons behind the issue so that we can make real, substantive societal and policy change to address barriers to care and provide education to people about how to best utilize the healthcare system. A system so frankly byzantine and broken that even seasoned health care workers and providers are often overwhelmed and confused.
Certainly decreasing unnecessary visits is crucial to cutting costs, and EDs are plagued with routine illnesses that could certainly wait and with drug seeking patients who game the fact that EDs don’t have their records to score prescription pain meds. But this proposal and its broad list of diagnoses goes too far.
There is a concept called the ‘prudent layperson’s standard’ in federal and state law. This standard requires health plans to cover visits to EDs if they are based on a person’s reasonable belief that he or she may be suffering a medical emergency due to the symptoms being experienced, not based on a final diagnosis. This proposal does not appear to meet that standard and despite the real problems that influenced the development of this new policy, it is simply not the answer.
