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.
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