The legislature in Washington State, like so many others, had a multi-billion dollar budget shortfall to fill this year due to the ongoing recession. Like others, it looked at the Medicaid program as a place where money needed to be cut from the budget. However, in what I believe to be a first in the nation (for now) approach, they directed the state Health Care Authority to find $72 million in savings specifically from Emergency Department utilization, and more specifically from those patients who over utilize the ED for non-emergent medical care.
The statutory language reads:
Emergency room visits in the Medicaid program will be limited to three non-emergent visits per year. The WSMA and the WSHA will be included in developing the criteria for defining non-emergent. [...] The department shall collaborate closely with the Washington state hospital and medical associations in identification of the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered.That doesn't sound too unreasonable, does it? Anybody who has ever been in the ER knows well that Medicaid patients come back again and again, and often for trivial or routine complaints. So the plan was to generate a list of agreed-upon non-emergent diagnoses and simply not pay for them after the third such visit.
It's sadly predictable what happened next. The HCA had been set a hard target of cost savings -- $72 million -- that they were mandated to achieve. They looked at the universe of true frequent flyers and their complaints and realized that they were not going to get to their goal by denying payment for the runny noses and toothaches that comprise the majority of non-emergent medicaid visits. So they expanded their definition of non-emergent diagnoses, and recalculated the savings. It wasn't enough, so they expanded the list of "non-emergent" diagnoses further yet, and again and again until they got the dollar figure they wanted.
The list, as it currently exists, consists of about 750 so-called "non-emergent" diagnoses established in the ER, for which the state will not pay, including such trivial, routine, and non-emergent conditions as:
Viral infection NOS
OK, I can get behind those as non-emergency ER conditions. I'd quite like to see those folks re-routed to clinics or PCPs. But wait, there's more! Other "Non-emergent conditions" for which the state will not pay include:
Asthma Exacerbation (acute)
Calculus of Ureter (i.e. kidney stone)
Syncope and collapse
I shit you not. There are many others -- these are just the most ridiculous "non-emergency" conditions that jumped out at me. It's also manifestly arbitrary and haphazard what made it onto the list and what did not. The HCA considers "Cholelithiasis with acute Cholecystitis" an emergency condition worth paying for, but "Acute Cholecystitis" is not. The state will pay for hand cellulitis, but not for the more dangerous foot cellulitis. All diagnosis codes which are "Sprains" or "Contusions" are denied, across the board.
For the record, the HCA did collaborate with the health community in that they met with physician and hospital groups, listened politely, and produced the diagnosis list unilaterally. Though the physician groups had many ideas for saving money such as case management, generic prescription utilization, and other ideas, they were rejected as outside of the statutory language of the budget. No mechanism was identified by which patients could be redirected to clinics, nor was there any allowance for the fact that trauma patients do not know in advance whether their injuries are fractures or sprains.
The idea, should this go into effect as planned, was that patients would redirect their care back to clinics and primary care providers. It's not going to happen, of course. Primary care, and especially urgent care, for medicaid patients essentially does not exist, not in any meaningful way. Sure, there are charity clinics and community health centers, but they are grossly oversubscribed and the access is minimal for acute or otherwise unscheduled care. The ERs remain open 24/7, and thanks to EMTALA, we cannot send patients away unseen. Sure, it's possible to do a medical screening exam at triage and deny non-emergent cases, but that's a liability nightmare, and would probably be a de facto violation of EMTALA if that was only done for medicaid players. (Though I am not a lawyer.)
There is no way, actually, to even know in real time if a medicaid patient presenting with a non-urgent complaint is one of the few who have met their three-visit limit. (97% of medicaid patients in this state visit the ER less than or equal to two times annually.) The ER doc and hospital will only find out after the fact when the claim is denied. Technically, we can bill the patient but that is a fig leaf because of course a medicaid patient won't be able to (or care to) pay cash for their ER visit.
There are so many things wrong with this that it's hard to know where to start. Of course, it's primarily a cramdown for providers. The state just decided not to pay for a certain arbitrary list of things, and docs and hospitals have no idea which patients that will apply to and no choice but to provide the services anyway. Which is in a way, nothing new, since we've dealt with the unfunded mandate of EMTALA for three decades. What is new, and troublesome, is that the non-payment will be decided after the fact based on an arbitrary and wrong list of diagnosis codes. This is not entirely new -- it's what went on in the '90s and resulted in Congress passing the prudent layperson standard, which essentially ended such practices. However, it's new in that this is the first time a governmental payer has tried this particular stunt, and I have a feeling that a lot of DHSH directors in other states will be carefully watching this experiment so see if it takes. If it does, this may be our future once again.
So look closely, my friends. Rationing is here, not covert rationing, but open and unapologetic rationing. It may be blocked before it goes into effect; I hope it is. If not, look for it to be coming to a town near you real soon.