In our last post, we looked a new initiative devised by the Health Care Authority of the state of Washington, in which Medicaid patient who abused the Emergency Room would be punished by having their excess ER visits paid for by doctors, hospitals and those purchasing private health insurance.  It is a bold plan, and roughly the moral equivalent of tossing a pile of warm manure to your spouse while saying, “Here, hold this while I round up some more for you.”

Clearly this plan is nor a solution to the problem.  Why?  Because the underlying problem isn’t who needs to bear the financial responsibility for inappropriate behavior on the part of the patients involved, but how to stop the inappropriate behavior at the source, and/or mitigate its adverse consequences.  These particular patients could not care less about whether Medicaid picks up their tab, or doctors, hospitals and those with private insurance do.  What’s important is that they themselves don’t have to.

So if we really do wish to solve the problem, what are the options?

The real issue at stake here is theft: the undeserved and inappropriate taking of emergency room goods and services.  It doesn’t really matter whether the taking is intentional or not, (it clearly is in the case of drug seekers, but may not be in the case of people with chronic conditions or who don’t know any better), the point is that one personal is wrongly taking resources that belong to others.  Since healthcare discussions are often highly charged with emotion and cloudy thinking, let’s consider what might be done in a similar situation, but in a slightly different field.

Suppose we were to have a fairly well-defined population of people who regularly call in fire alarms every time they spot a fire.  They do this regardless of whether it’s the fire is a lit candle, a gas kitchen stove, well contained in a fireplace or a pile of burning leaves in someone’s yard.  Some of them even call in an alarm when no fire of any kind is present.  Each time they do, the fire department responds with a full complement of trucks, ambulances and other gear, only to find that their efforts are either unnecessary or ridiculous overkill.  Not only is this activity burning up millions of dollars in fuel, tires and manpower, but it’s dangerous.  Each time the fire department responds to a false alarm, there is an excellent chance that their response to a real emergency will be delayed.  How would we deal with this situation?  There is a wide range of responses that are far more appropriate than having the local fire district announce that, henceforth, the cost of these false alarms will simply be passed on to the miscreant’s neighbors.

The first is education.  Since the population causing the problem is relatively small and well-defined and the cost of each false alarm is so high, one could easily spend a modest amount of money on a few employees whose full-time job is to meet each perpetrator, learn about their case, and attempt to directly influence their behavior.  Perhaps the individuals involved really don’t know what constitutes a real emergency.  Or maybe they’re too lazy to get their help from a local clinic during regular business hours.  It’s certainly important to know which it is.  It’s not clear whether Washington’s Health Care Authority tried this approach or not, but one can buy a great deal of training and social pressure for $35 million.  This certainly ought to be Plan A.  Logically, a second level of response would be applied to those who either will not, or cannot, respond to intensive education alone: reward and punishment.

Reward can be hazardous when inappropriate behavior is concerned.  The worst thing one can do is encourage everyone to behave badly.  But one systemic change that would be good for everyone is to convert all insurance – including Medicare and Medicaid – to high-deductible coverage tied to healthcare savings accounts (HSAs).  For those on Medicaid, the amount of the HSA would be provided by the government as part of the healthcare benefit; after all, the same amount of money almost certainly would have been spent anyway on conventional benefits.  But the most important part of these HSAs has to be that there is some reward or sweetener for not spending all of the money in them.  You get to use the interest earned to spend on anything you want, or to roll over the unspent amount into your retirement, or some other combination that provides each individual with a direct financial benefit in exchange for not spending the money on marginally beneficial healthcare goods and services.  The nature of human greed dictates that some portion of the insured population will respond by reducing their use of medical services.  But let’s not kid ourselves.  Simply utilizing HSAs won’t be enough to stop thousands of Medicaid patients who truly have no qualms about stealing the ER.  Some form of punishment will be needed.  The only real question is the form that it should take.

There is no greater challenge in healthcare than devising an appropriate punishment for those who abuse the system, but have nothing to lose.  You can’t bill them, for they can’t pay.  You can’t put liens on salaries they’re not earning, or houses they don’t own.  You can’t even seriously threaten to take away their Medicaid benefits, since they can always use point to the Emergency Medical Treatment and Active Labor Act (EMTALA) and show up at the nearest ER.  Even threatening them with jail time won’t necessarily do any good.  In the big picture incarceration is at least as expensive as healthcare; especially when one considers that prisoners are entitled to free food, lodging and healthcare.  No, in this case it’s not just that the punishment should fit the crime, but the punishment should prevent the crime.  There is only one way to accomplish this: to remove the reason these patients are going to the ER repeatedly for non-emergencies.

Simply don’t give them what they want.

Some might argue that 11,000 Washington Medicaid patients all want different things, but that’s only partly true.  Unless you’re a hospital buff, there are only two things a sane person could want in an emergency room – treatment or companionship.  (We’ll leave aside the issue of the mentally ill going to ERs.)  This makes the solution so easy that it can even be reduced to one of those guidelines of care that government agencies find so irresistible.

Step #1:  Medicaid ensures that it has a network of clinics available that agree to see Medicaid patients on an urgent care basis during regular business hours.  The goal of this network is to ensure that patients are not forced into the ER as a result of an unreasonable lack of access to routine care.

Step #2:   Medicaid maintains a secure, easy-to-use and easy-to-access and easy-to-search website in which ER staff may easily log the fact that a Medicaid patient presented for an ER visit, the diagnosis, and any treatment given.

Step #3:  Medicaid asks all hospital emergency rooms to kindly inform it whenever one of its beneficiaries presents for a condition, or in a manner, that the treating physician believes constitutes an abuse of the medical emergency treatment system.  The criteria for “system abuse” would be left entirely up to the treating provider.  (The website described in Step #2 will be especially useful for helping to identify drug seekers and other patients who are doctor-shopping or routinely abuse the ER.)

Step #4:  For any Medicaid patient seen in the emergency room who providers duly evaluate and judge to be presenting for a condition that does not constitute a true medical emergency, treatment is withheld or (in the case of conditions like asthma or diabetes) limited to that required to tide the patient over until urgent care clinics open on the following business day.  No narcotics may be given or prescribed on any such visit.  Instead, the patient is instructed to go to the nearest urgent care clinic in Medicaid’s network either immediately, or during the next business day.

Step #5:  Medicaid agrees to indemnify and hold harmless any healthcare provider and hospital following this policy in good faith against lawsuits or claims of negligence or improper withholding of care.

Step #6:  If Medicaid should be bold enough to try this approach, all we here at TRTH humbly ask is to receive a quarterly check for 1% of the money saved on ER visits.

Seriously, this is the sort of problem solving that our political and regulatory leaders are supposedly paid to do.  Yes, it’s easier and requires no thought to simply dump the problem on providers, hospitals and the private healthcare system, but thoughtlessness, complexity and spending other people’s money are exactly why we’re on the road to hellth rather than health.  We deserve far better policies than we’re getting.

Perhaps the question asked of voters in next year’s upcoming elections should be: “How’re those politically controlled, heavily regulated, idiotically complex, thoughtless, passing-the-buck and spending-other-people’s-money healthcare laws and policies workin’ out for ya?”

Recently the state of Washington announced that it had had it with paying for the Emergency Room (ER) abuses of its Medicaid patients.

“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…

…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 non-emergencies 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.’”

To provide guidance with respect to what Washington’s Health Care Authority considers a true emergency, the state published a list of over 700 diagnoses that it believes should be addressed electively on an out-patient basis rather than in the Emergency Room.  Controversy has arisen because some of these are arguably difficult to distinguish from other conditions that most people would agree do constitute emergencies.  Some of these “grey area” diagnoses include shortness of breath, hypoglycemic coma, “non-specific” chest and abdominal pain, food poisoning, bacteria-caused infections such as salmonella enteritis and shigellosis, sprains, gall stones, “hemorrhage (i.e., bleeding) not otherwise specified”, “syncope (i.e., fainting) and collapse” and abdominal pain in the left-lower quadrant.  You can appreciate the problem immediately posed by emergency room physicians.  Since left-lower quadrant pain is one of the most popular presentations of acute appendicitis, how is the average schnook supposed to know that it’s not appendicitis (which even the folks at Washington Medicaid agree really is a true emergency) unless one is evaluated by a real live doctor?  After all, even the most malingering malingerer is perfectly capable of developing real and serious disease at some point in their life.

It seems that Washington’s doctors object to this “innovation” for two reasons.  The first is out of concern for the fate of patients who might be discouraged from coming into the Emergency Room when they really did have a medical emergency.  This is no surprise; most doctors tend to feel strongly about that sort of thing.  The second reason was out of a very rational concern that Medicaid’s “frequent flier” beneficiaries might not stop coming to the ER with non-emergencies just because the state refuses to pay for the extra visits.  After all, if the state wasn’t going to pay for these visits, the hospitals and the ER physician groups seeing these folks will have to foot the bill themselves for patients whom they are required to see by law.

(We forget.  What is it called when you’re unwillingly forced by other people to do work for them without any form of payment?  Never mind…it’ll come to us eventually.)

So the docs did what every re-blooded American is taught to do from the age when they can first understand television commercials: they filed a lawsuit.

“The lawsuit, which asks the court for an injunction, says the state did not follow proper rule-making procedures, ignored lawmakers’ directions and is violating state and federal Medicaid laws, including “prudent layperson” standards governing the coverage of ER visits.”

One of the big objections cited by the physician groups is that their ideas and suggestions were essentially ignored in the process of coming up with this scheme.  Even the state’s medical director for Medicaid, Dr. Jeff Thompson conceded that the entire process was the result of a one-sided and single-minded need on Medicaid’s part to cut $35 million from its ER budget.  Moreover, there is really no question that many of these visits were clear and unadulterated abuses of the system.

“Only a small minority — about 3 percent of Medicaid patients who use ERs in a year, or about 11,000 patients — seek care in ERs more than three times a year. Those patients have been specifically notified by Medicaid about the changes, Thompson said.

A few patients visit ERs 20, 30 or more times a year, he said. In 2005, the top Medicaid ER user, a 27-year-old woman, visited ERs 172 times, mostly with migraine and headache complaints, according to DSHS.

As many as half the high-use ER patients are seeking drugs, Thompson says, and because ERs are so crowded, patients with true emergencies may not get the attention they need.”

For the purposes of thinking about this whole affair logically, let’s restate the basic problem:

There are about 11,000 out of roughly 367,000 Washington Medicaid patients who appear to be repeatedly abusing the state’s ERs.  They’re costing Medicaid tens of millions of dollars in probably unjustified expense each year, so one of our single-payer government insurers decided to do what they do best: simply dump the cost and the problem onto the private sector in the form of an unfunded mandate to see these patients anyway.  Who will ultimately pay for this?  Why everyone with private insurance or who pays for healthcare out-of-pocket, of course!  Anyone who thinks that you can simply bill these patients for the amounts Medicaid won’t cover is dreaming.  The vast majority of them are unemployed, and drug-seekers are notoriously unreliable bill-payers.  Unless the doctors and hospitals are to go out of business, they’ll have to raise their rates to private insurers.  With its single-payer monopsony on services delivered to old folks and the disabled, Medicare won’t contribute a cent.  (In fact, both the ObamaCare legislation and the recent budget ceiling agreement call for Medicare to cut payments to providers by nearly three-quarters of a trillion dollars over the next ten years.)  So as a direct result of government regulation, its single-payer insurance coverage practices and the “Affordable” Care Act, business, employees and individuals – and that probably includes you – will see health insurance premiums become even more unaffordable in 2012, after a 9% increase in 2011.

Too bad they’re the same taxpayers who are already paying for Medicare and Medicaid in the first place.  This isn’t a solution to the problem of inappropriate spending; it’s just putting the purchase on a different credit card.  Of course with innovative thinking like this, other states are already looking to follow suit.  Just as no good deed goes unpunished, in healthcare no bad idea goes un-imitated.

Let’s try to apply some common sense and come up with a better solution, shall we?  That’ll be the topic of our next post.