The Washington State chapter of the American College of Emergency Physicians has opened another avenue of discussion in the hopes of overturning a state Medicaid policy that limits nonurgent emergency department visits.
The chapter filed suit on Sept. 30, the day before the new Medicaid policy went into effect. And now, the organization has offered what it hopes will be an alternative solution to help the Health Care Authority (HCA) of Washington meet its budgetary requirements, Dr. Stephen Anderson, president of Washington ACEP, said in an interview.
The plan is aimed at "reducing the perceived ‘overutilization’ and ‘inappropriate’ use of the emergency department that does not impose an arbitrary cap on emergency room visits," according to a draft of the plan made available by Dr. Anderson.
Among the elements of the plan are requiring timely follow-up by primary care physicians, denying payment for ambulance transportation for nonemergency conditions, creating a real-time database to track ED visits, and closer case management. For instance, the patient would be notified when they had used the ED inappropriately.
The plan has not been discussed with the state as of press time, but Dr. Anderson said he is hopeful that the ACEP chapter could reopen negotiations with the HCA.
It is not the first time a payer has attempted to limit ED visits. ACEP successfully got New York State to reverse a policy that would eliminate payment for ED visits for Medicaid patients in the early 1990s, said Dr. Sandra Schneider, ACEP president, in an interview. And the prudent layperson standard came into use as a result of managed care’s efforts to pare back emergency visits, she said.
But the Washington State policy is indicative of a trend in response to a tight fiscal environment; other states are looking at similar policies, said Dr. Schneider – in part because the payers know that "we are the only physicians in this country who are required to see patients," she said.
In 2010, the Washington State legislature, in response to a growing deficit, ordered across the board cuts. Medicaid was not spared, and the HCA was ordered to decrease nonurgent ED visits in collaboration with the state’s medical societies.
Dr. Anderson said that ACEP, the Washington State Medical Association, the Washington State Hospital Association, and the Washington chapter of the American Academy of Pediatrics, among others, met with HCA officials for months to engineer a list of nonurgent conditions.
An original list of 700-800 diagnoses considered nonurgent was floated by the HCA. Through negotiations, "we trimmed it down to 350 diagnoses that we all agreed should be in primary care," Dr. Anderson said.
But when the final policy was issued, the list was back up to 700 conditions that would be considered nonurgent. Beginning Oct. 1, the Medicaid program is paying for only three of these nonemergency visits per patient per year.
"This is a realistic strategy to change clients’ behavior and improve patient care as well as assure taxpayers that we are addressing the state’s continuing financial crisis," said HCA director Doug Porter in a statement issued by the agency announcing the policy in late September.
The list of nonurgent conditions includes chest pain, sudden loss of vision, asthma, miscarriage with hemorrhage, kidney stones, and gallbladder problems. Dr. Anderson said that all of these conditions are typically considered emergent and that they should be exempt under the prudent layperson standard. But the HCA has said that it does not believe that standard applies to its clients, said Dr. Anderson.
Dr. Jeffrey Thompson, HCA’s chief medical officer, said that the standard applies only to managed care, but not to fee-for-service Medicaid. The Medicaid program is "trying to balance access, quality, and cost," said Dr. Thompson, in an interview. To do that and meet the legislature’s requirements, the HCA had to change eligibility, reduce physician payment rates, or change benefits, he said. The first two options are prohibited under various laws, "so the only tool left is to change benefits," he said.
The benefit change should affect few Medicaid recipients, said Dr. Thompson. State data indicate that 13% of recipients account for 43% of all ED visits, he said. Those are costly visits; 28% of all ED visits in the state are paid for by Medicaid. The cost in 2010 was $98 million for 327,965 visits.
The HCA is trying to identify the 11,000 recipients who have been deemed frequent users of the ED. That’s only about 3% of the 2.1 million total Medicaid clients in the state, said Dr. Thompson.