Denying payment for unnecessary emergency room visits

Just when American healthcare system seems so dysfunctional that it seems impossible to imagine how it could be screwed up further, a decision is made that restores one’s faith in the creativity of Man.  But before you run out of guesses as to which particular decision we’re talking about today, we’ll just blurt it out.  We are referring to a recent decision by Washington State Medicaid to deny payment for emergency room evaluations incurred by its beneficiaries that this public insurance entity decides were, in retrospect, “unnecessary.”  No “three strikes you’re out”, no quibbling over the diagnosis list, no excuses – Medicaid has washed its hands of these people.

We’d previous written about this story, when the folks at Washington Medicaid were just getting warmed up at the end of 2011.  Little did we know we’d be revisiting the issue so soon.  Have the people running the Medicaid program in Washington State gone nuts?

Like nearly all public healthcare insurers, Medicaid in the great state of Washington is rapidly going broke.  The state is faced with a $1.4 billion budget gap in the FY 2011-2013 biennial state budget, and has begun cutting all sorts of benefits to its Medicaid population.  Thus far, these have included elimination of the Basic Health Plan that delivers health care to 35,000 low-income individuals, elimination of routine dental care for persons with developmental disabilities, long-term care clients and pregnant women; increasing the level-of-care requirements for personal care services; elimination of the Adult Day Health program; utilization management for mental health services; and elimination of medical interpreter services and, of course, reductions in payments to clinicians.  But these pale in comparison with the innovation the state has devised in terms of saving on its annual Medicaid emergency room bill.  It’s a program which, as nearly as we can tell, hasn’t yet been tried elsewhere.  Call it “Heads We Win, Tails You Lose”.  Here’s the story from The Seattle Times:

Intent on cutting state budget health-care costs, Medicaid officials say the program will no longer pay for any medically unnecessary emergency-room visits, even when patients or parents have reason to believe they’re having an emergency.

The rules — arguably more drastic than an earlier proposal to limit Medicaid patients to three visits per year for nonemergency conditions — would block payment for ER visits for about 500 different conditions.

They would apply to all adults and children on Medicaid, with no exceptions, such as someone being brought in by ambulance or from a nursing home, or when patients have neurological symptoms or unstable vital signs.

Of course the need for some sort of action to be taken is pretty straightforward: a certain number of Washington Medicaid patients are clearly abusing the system and costing taxpayers millions in the process.

Dr. Jeff Thompson, chief medical officer for Washington’s Medicaid program, said the state is committed to paying for medically necessary care.  But many times, he said, patients go to ERs when they would get better, and less expensive, care in a primary-care ‘medical home.’

‘The ER cannot be the medical home of the 21st century,’ he said. ‘We will not pay for diaper rash treated in the emergency room.’

Currently, there is ‘tremendous overuse and abuse’ of emergency rooms, Thompson said — amounting to at least $21 million a year.

Some patients show up as many as 120 times a year for costs of $20,000 to $25,000, he said, but until now, most ER doctors and hospitals have done little to deter them because the state paid the bills.

‘The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER,’ Thompson said.

‘They have not stepped up as leaders to actually be better stewards of care and safety and the public resources,’ he said.

Under the new rules, ER services not paid by Medicaid wouldn’t be billed to the patient, leaving the doctor or hospital on the hook.

While every reasonable person can agree that it defies logic, reason and good medical sense for any individual to rush to the emergency room for non-urgent or even trivial problems, one simply must treasure the rather unique assertion that emergency room physicians and hospitals are at fault for “abusing their privileges” as providers of services to the poor.  As a rule, public insurance program payment is so poor hospitals and doctors lose money on virtually every Medicaid patient they’re forced to see.  Believe us when we say that any patient showing up in your ER or office every third day is about as welcome as a porcupine in a waterbed warehouse, especially if you’re paying for the privilege of seeing them.  One has to wonder if Dr. Thompson had to rehearse his lines in a mirror to master the art of reciting them without laughing.

For those of you who may not be familiar with the ins and outs of emergency rooms, federal law mandates that each and every person walking into one be seen and evaluated regardless of their ability to pay.  This is a result of the Emergency Medical Treatment and Active Labor Act (EMTALA), which was passed by Congress in 1986.

Simply put, EMTALA says that every hospital that operates an emergency room and accepts federally funded insurance must by law, see, evaluate and, if necessary, treat each and every homo sapiens that walks, crawls or swims into their ER regardless of race, sex, nationality or ability to pay.  If the doctors and hospitals involved lose money in the process that’s just too bad.  If you don’t like it, close your emergency room.  (Coincidentally, this last idea is one that seems to be catching on around the country as a direct result of the less-than-generous payments that publicly funded insurance is paying these days. A 2009 study showed that nearly one in every three emergency rooms in the United States has closed their doors over the past 20 years.)

So here’s the actual logic underlying this new Washington Medicaid initiative:

  1.  ER docs and hospitals are required by federal law to see and evaluate anyone who walks in – at their own expense if necessary.
  2. If a Washington State Medicaid patient walks into the ER with a non-emergency and the doctors and hospitals see them as required by law, Medicaid will refuse to pay on premise that the provider are “abusing the system” and being lousy “stewards of care and safety and the public resources”
  3. Since the doctors and hospitals are abusing the system by simply being there and doing what the federal government has said they must, they should not even be allowed to try to bill the patient directly for the visit.

It may not have occurred to Dr. Thompson and the other folks in charge of this “innovation,” but it seems self-evident that when a person repeatedly goes to an emergency room for problems that are not medically urgent, we are really talking about a social problem rather than a medical one.  Heck, other states have recognized this reality.  Oregon has launched a very useful and cost-effective program that essentially assigns a social worker to each high-cost Medicaid recipient.  A major part of their job is to divert ER-abusing patients away from the emergency room and into keeping their regularly scheduled clinic appointments.  As it turns out, sucking up an hour of social worker time is far less costly – and far more effective in changing behavior – than sucking up an hour of hospital and ER time.  It makes sense once you bother to think about it.  What the new Washington Medicaid program does is simply convert a social problem to an economic one, and then dump it on doctors and hospitals in the private sector.  If this is the best government thinkers can do, we are all in some serious trouble.  Heads should roll as a result of pulling this sort of stunt.  Where’s the Queen of Hearts when you really need her?

However beyond the issue of the people running our healthcare programs are rational, competent, or even looking out for the best interests of taxpayers, there are two other more profound and troubling issues raised by this policy decision.  Issues that affect all of us.

First, is there any limit to what the government may require law-abiding citizens to do without compensation?  EMTALA requires doctors and hospitals to see patients regardless of their ability to pay, but does it free insurers of their obligation to pay for the care of their beneficiaries?  Do all insurers have the right to do this, or just public insurers?  How does requiring free people to work without compensation differ from slavery?  Where are the limits?  Can firemen be required to put out fires regardless of a community’s ability to pay them?  Can police or firemen be required to work without pay on the principle that people’s lives may be in danger?  Or should they only be paid if there really was some real risk to life and limb?

Second, if people – patients in this case – are behaving irresponsibly by, for example, going to an emergency room for diaper rash, why do they have no obligation to bear any financial responsibility for their actions?  If the issue is simply that these patients are poor, why are any financial penalties levied on the poor?  Why are the poor required to pay for parking tickets – an abuse of public space – but not clearly unneeded emergency room visits – an abuse of a private space?  Is the government in the business of protecting its citizens, or merely itself?  Where does the public interest end, and something more akin to abuse of power begin?

We may have already crossed that line.

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.

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  • Stefani Daniels

    Just say no….I mean the hospital.  Follow EMTALA.  Give the patient the medical screening  (use a PA or ARNP) and if it is determined that it is a non-emergent need, refer to community resource OR better still, to the primary care unit adjacent to the ED.

    • ACEP

      What “community resource” or “primary care unit,” Stephani?  Do you know how few exist and of those that do, how few accept Medicaid insurance?

  • Anonymous

    Trying to make sense of WA’s policy is useless. It’s simply a power play.  WA is trying to leave hospitals and ER docs and the patients holding the bag, and there is a good chance they will be able to do so. 
    Another aspect to this would be funny if it were not so vicious:  The Medical Home aspect.  Most of these medical nirvanas do not exist, and if they do, they often–wait for it– won’t take Medicaid patients.
    ER docs being the bad guys here?  What a joke.  They (and the patients) are victims of a dysfunctional system that incentivizes physicians to do whatever they can to avoid the poor and primary care, and then, quite deviously, punishes those ER docs who do put themselves on the line to provide safety-net care to people no one else gives a damn about. 

  • David M. Escobar

    Thank you for parsing the issue so well.  As a medical student training in WA state, I’m appalled at the policy being enacted.  It is an illogical and heartless policy that borders on the criminally negligent. 

  • John Ballard

    Please help me understand why there is not a more robust program of community clinics, not just in Washington but all over the country. Posts like this one should never need to be written. I know that in Georgia hospitals cannot be approved by whatever authority is responsible without first applying for and getting approved a “certificate of need.” Here in Atlanta the big hospital systems compete for choice opportunities like bidders at auction while the places most in need are poorly served. Add to this mix Grady Memorial, the charity hospital, and the picture becomes even more skewed. Poor people don’t seek medical care simply to be a pain in the butt for ED. They go there because they have no other resource. 

    The safety nets are not there and there is no excuse. Could it be that big hospitals are opposed to community clinics as a matter of policy? Something is clearly standing in the way. And Medicaid beneficiaries would certainly not object.

    • Anonymous

      There is not a more robust program of community care clinics because, first, they cost money and American society does not to pay for them,  and second,  because doctors and nurses do want to work at them because working at them entails too much work and not enough money.

  • Margalit Gur-Arie

    This is just the harbinger of more to come. Placing doctors in the role of stewards of resources, whether public or private, whether scarce or plentiful, presents a terrible conflict of interests. For these destitute Medicaid patients showing up at the ED, EMTALA is the weapon of choice, and for better-off patients it will be the nouveau capitation (accountable care).
    Either way physicians’ income (and ethics) will be placed at risk for patient behavior, social realities, lack of planning, policy making, you name it. All in a patient-centered fashion, of course.

  • Anonymous

    Difficult to balance “I feel chest pain and all the PSAs say to go to the ER and don’t delay,” with “you have indigestion and a bill for $8,000.”

  • GPZ

    How about you do what the UK does and have a GP clinic on site (at the hospital) 24h a day and refer non emergent care to them from the ED. Saves time and money for everyone involved. 

    • John Ballard

      Actually locate an appropriate resource where the needs appear?!!!
      What a concept.

    • Anonymous

      Excellent idea.  The great thing about us family docs is that we don’t need sleep or rest or time with our families.  And since there is such a surplus of us, we can also cover daylight hours as well. Can I sign up for the midnight to 8 am shift?  Eight days a week? I’d also like to work Christmas and my children’s birthdays if that could be arranged. 

  • Anonymous

    The resonance of Dr Perednia’s cri de coeur is dissipated like flatulence by this discordant note:   

    “a certain number of Washington Medicaid patients are clearly abusing the system and costing taxpayers millions in the process.”Why those wily bastards! The scheming wretches, looking to take advantage of the state’s unimpeachable system and its swank ER health treatment that way!First their number is not “certain”, otherwise you would certainly have specified it. And if it were certain (and it probably can be determined – see the work done in Camden county, NJ, and other places) you would begin to have a means of dealing with the challenge systematically. And in obtaining that certainty, you’d almost certainly find the challenge of misallocated millions was not a matter of epidemic diaper rash. Certainly competent medical professionals know that only too well.A rant against the systemic defects is where your philippic should begin and end, Dr. P, rather than with a self-diminishing screed fingering the devious collusion of the unlucky.

  • Gene France

    Why doesn’t city hall provide a screening to see if they are ER worthy?

  • Dieter Soerensen

    A clear and succinct piece of writing. In the UK not withstanding the earlier post, there is a further alternative of installing a triage practitioner in the ER department who screens the incoming patients, this will be cheaper than a GP based system and be 24/7. Alternatively, a walk in center coupled with education and dedicated helpline numbers has helped reduce the non emergency – i need a paracetamol from ER  culture – admissions.  You are correct it is a social phenomenon and needs to be addressed by society (Politically & Education) and not by an accountant culture.

  • Angelo Falcone

    As a practicing emergency physician for almost 20 years I find it mind boggling that the ER is first seen as the safety net taking care of all society’s ills, bring me your patients that are intoxicated (no drunk tanks), psychotics (close all the psych facilities), have URIs (no PCP access) mandated by EMTALA. Then turn around and say we are abusing the system. To what ‘system’ are we referring? Come walk a mile in my shoes maybe it will give you a clearer picture of the issue.

  • Steven Reznick

    Before you limit access you need to educate the public. Put the money into health education and hygiene classes in the schools including basic first aide. Extend the education to the community. Put in a Medicaid phone triage hot line so sick individuals can ask questions and receive reasonable answers and then consider a program like this one. While ER physicians didnt go into the specialty to be primary care physicians, many hospital administrations treat the ER as a profit center and encourage community wide use and abuse.

  • Anonymous

    Until you have worked in an emergency room, you can’t imagine the complexities surrounding reimbursement, what patients to see, how to staff, who pays for what etc.  An ER must be staffed, at all times, for life-threatening emergencies, I repeat, emergencies.  Where I saw the system fail was in the Triage process.  A smart hospital will have an ER and walk-in clinic side by side.  An efficient Triage RN can send the non-acute patients to the walk-in clinic which requires much less staff and much less equipment.  The walk-in clinic can educate patients who, inappropriately, went to the ER to make more responsible choices and have better follow-up or whatever will make them healthier health consumers.  This is a no-brainer.  ERs cannot afford to provide walk-in services as it must provide staffing and equipment for every patient that walks through their door as if it were a life-threatening situation. Enough said.

  • Myles Riner

    The sad thing about WA’s policy is that it is distracting us all from addressing the real opportunities to reduce health care costs.  So called ‘unnecessary ED visits’ account for a very, very small portion of state funds that are expended for unnecessary or ineffective care for Medicaid enrollees
    This is what comes of a Legislature that says ‘cut this much money from the WA Mediaid budget:  we don’t care how you do it’ and the State’s health department responds with ‘well, let’s try this’ without bothering first to seriously consider, and study, the health care consequences of the approach.  This ill-conceived policy undermines the financial viability of an already shaky emergency care safety net, which EVERYONE relies on.

  • Soumiya Prakasam

    I believe WA state is not going about this the right way like everyone else, but we have to be practical and realize the healthcare system does not have enough money to keep things the way they are.  I think Oregon might be onto something.  Can we also discuss how Press-Ganey is an added evil to the system? I work at a very nice community hospital, and with that being said, people who have primary docs at the “poorer” hospital come to our hospital instead.  This adds unnecessary tests to be done and increases costs to the system due to lack of past medical records.  Can we focus less on having a good survey from someone with a bruise on their leg to concentrating on how to improve the system as a whole?

  • Anonymous

    any attempt to contain costs that shifts no risk to the patients is doomed to fail.

  • Bret

    What Washington State has done is essentially made slavery a legal enterprise when caring for a Medicaid patient. Leveraging EMTALA and throwing out prudent layperson while placing all burden on the backs of the EPs in that state (no pay and all liability) This is unconstitutional (see 13th Amendment passed in 1865). Filing suit in a Federal District Court seems a reasonable course of action….

    • JenniferL


      The 13th Amendment outlawed slavery of Washington State ER staff in very short clear language: 

      “Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction.”

      What could be more clear? Of course the totalitarians say that the 13th Amendment does not apply to physicians.

  • Anonymous

    This post, and all of the comments ignore one reality, and THAT is the real crime in health costs today – personal responsibility and judgment. 

    EVERYONE can afford a small copayment ($2? $5?), even the poorest of the poorest medicaid patients in Harlem & the Bronx.  I have practiced in these locales, and have yet to see a patient without a cellphone.  Many patients on welfare & medicaid work and make a little cash off the books, have cars and flat-screen TVs, iphones and ipads, and most everything else the rich suburbanites have. Spending that $5 to be seen in the ER for a pregnancy test, and be told that they need to buy an OTC pregnancy test but the ER is keeping their $5 copay anyway, that would end the problem FOREVER.

    What they DON’T have is a sense of responsibility for using a finite resource, the way we would have if we are required to pay for a service.

    And i echo the sentiment of not ever working in an ER. It’s very irresponsible of Dr.Thompson to impugn ER docs who don’t have the luxury of refusing nonpayers, that we internists and everyone else has in an office or even outside medicine.  It’s even worse coming from an ‘administrative’ MD who doesn’t see patients at all, and gets a salary for essentially spewing about something he can’t possibly understand.

  • Joe Ketcherside

    Understand EMTALA, but why do ERs in my area of the US advertise on billboards that you can download their mobile phone app to show which ER in town has the shortest waiting time to be seen? Seems they are soliciting non-emergency patients to come in. That is abuse of the system. Bet they would love to have an app that only displays times if you have commercial insurance.

    I like the idea of defining what will be paid for, and letting the market sort out for themselves how to meet the criteria. For too long we have told hospitals we will keep paying, but please find a way to lower costs. This is what we need – tell them we will no longer pay, and they have to find a way to stay in business. That is motivation that was lacking before.

    • Anonymous

      hoo boy. talk about disconnected from reality. the “market” will not sort itself out if the patients are paying $0 for their care.

      you are asking the hospital to “find a way to stay in business” in the setting of a large patient population they are legally mandated to see, but will no longer be paid to see. the hospital will “find a way to stay in business” by either using trickery to convince medicaid that the visit was a legit emergency that qualifies for reimbursement, or it will make up the loss by raising the prices on services it CAN collect on. or it will go out of business, leaving one fewer hospital to care for patients and the surrounding hospitals will take on the additional patient load. which of these scenarios do you envision leading to “lower costs?”

  • Robert Bowman

    The Congressional Budget Office reviewed dozens of programs designed to target high risk and high cost patients. The finding was that such management was at least as costly to run as the health care costs saved. The CBO review did not consider the workforce lost when personnel are converted to “cost control” or “shared savings,” etc. Also since many of these nurses, advanced nurses, and others that can deliver health care, their services were lost from delivery of basic services. Where populations are more stable and have intact structures, cost controls work. Cost controls have failed where stability has failed.

    When 30,000 zip codes with 200 million or 65% of the population have only 25% of workforce and the least available primary care workforce, the consequences are numerous.

    Those accessing ERs and Urgent Cares inappropriately via Medicaid also include working moms, dual low wage earner families, and those keeping kids in school who also find their options small for care at all or for care at hours when they can access care.

    Matters are not likely to improve for those left behind with even less health spending sent to 30,000 zip codes as even more is spent in 1000 zip codes with 50% of health spending already, with cuts in Medicaid, with increasing costs for electronic records for little reward (and more regulations), and requirements for more physician and personnel time to get less done.

  • Andy Edley

    This is what happens when government gets involved in something they know nothing about.  Government was never set up to deal with medical care.  As long  as people have the idea that someone else should pay of my medical care, and I should not have to be responsible for my actions you will have abuse.   Until we get back to personal responsibility this kind of problem will exist.

  • Anonymous

    Uh, doesn’t the Patient Protection and Affordable Care Act (PPACA) address this problem? Uh, didn’t President Obama model the PPACA after Romneycare in Massachusetts? Uh, didn’t the idea of the individual mandate initially come from Newt Gingrich? Seems to me, back when Gingrich was Speaker of the House, he strongly supported the individual mandate and wrote extensively about it. So, along comes Barack Obama and he gets a divided Congress to pass the individual mandate and Obama signs it into law and, all of a sudden, it’s no longer a good idea? Get real! The unnecessary emergency room visit problem would be solved overnight if we had the individual mandate because everyone would have access to primary care coverage and everyone could get regular checkups to avoid going to the hospital emergency room. But, as usual, Republicans always try to solve problems backwards. Romney and Gingrich need to grow some gonads and admit what they strongly supported in the past. Couple of hypocrites!

  • Anonymous

    Yes, the ACA addresses Medicaid big time as Title II, not directly about ER visits as I have read so far but it should “come out in the wash” of the many, many issues.  This was a great post to show how screwed up our health care is AND how, with so much proverty in this country we cannot dissociate health care from social services.  Getting a social worker involved IS part of primary preventive care.   And if there aren’t enough social workers, try other professional workers with social skills, other educational measures.  This is an area where jobs and funding should be increasing.  Not at the high tech or the next new statin or blood pressure medication.    

    Oregon is right next to Washington state.  One would think (I guess foolishly) state governments would check things out elsewhere before implementing such a measure.  

    BTW – Inside National Health Reform by John E. McDonough is comfortable reading about the ACA and goes over each of the 10 Titles along with the history of getting closer to a universal health care SYSTEM.      

  • Anonymous

    I find it difficult to understand how a patient would understand that his/her case would be unecessary medical condition before seeing an healthcare professional.  I teach CPR in a Nursing School, and it is common for people (especially women) to ignore the warning signs of imminent heart attack, because the early warning symptoms usually seems trivial (unecessary).  Emergency room is never a lovely place to be; it is boring, time wasting, and functionless; but for people who are sick, they must endure the conditions with the hope to get better.
    There is nothing interesting and exciting about the Emergency room, people only go there because they believe they are sick, and sometimes, because they have no health insurance.  Therefore, to punish them in any manner or form is simply bad management.  Of course, when bad leaders run out of ideas, they turn against the people they are elected/appointed/hired/etc. to serve.  This is an example of a toxic-decision. 

    • Anonymous

      “…about the Emergency room, people only go there because they believe they are sick…”

      that statement makes it clear that you have never spent a significant amount of time in an ER. Let me clarify – at least half, probably more like 75% of those seen in ER absolutely know that they are not emergently ill. Again i think instituting a modest copayment with medicaid & medicare is very reasonable and will weed out those going in for pregnancy tests etc.  Commercial insurers already do this, and i myself am reluctant to go to an ER with my $50 copayment. Having a $5 copayment is, I feel, something EVERYONE can afford.

  • Anonymous

    OMOWEMBA-clearly you have NEVER worked in an emergency room…you would be amazed at the bullshit people come in for….diaper rash, hangnails, yeast infections, FOOD, the common cold,skinned knees, belly button lint, etc etc etc.Most of these thing don’t even require a visit to a DOCTOR, let alone an emergency rooms.These same folks also use 911 as a fancy taxi.It is as though common sense never even existed. You are naive if you think people are only coming to the ER for actual emergencies. 

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