Medicaid Rule for Emergency Departments Used a Hammer to Tighten a Screw

There are a thousand places to look for cost savings in healthcare, but this week in Washington State officials grappled with one of the most visible of those: emergency care.

Thankfully, Washington Governor Christine Gregoire has suspended implementation of a rule that would have denied emergency rooms payment from Medicaid if the patient was diagnosed with a range of certain diagnosis deemed to be non-emergencies. The problem with that strategy is that neither the patient nor the physician knows whether the chest pain a patient walks in with is something serious like a heart attack, or something not so serious, like acid reflux. 

As MedPage Today put it, Washington State was set to begin “determining coverage for emergency department visits based on final diagnosis codes rather than the symptoms that brought the patient in.” And how many diagnosis had the Washington State Health Care Authority deemed “non-emergent”? More than five hundred.

Now, emergency physicians know that some patients who arrive for non-emergency conditions do so for one simple reason: there is no alternative location for them to go to receive the care they need. At the same time, emergency rooms don’t turn people away – federal law prohibits it. That is a good law, and many emergency physicians love their specialty precisely because the care we provide is not determined by the patient’s ability to pay.

The federal law is also a reason why the real effect of the Washington law would have been to simply shift the cost of caring for many Medicaid patients from Medicaid itself to the hospitals and physicians who provide the care. That is a solution mismatched to the problem, sort of akin to using a hammer to tighten a screw.

The good news is, there are ways to both reduce costs in the ER and provide better care. We, along with our partner hospitals, have implementing some of them for years:

• Fast-track care and expedited medical evaluation. Our Emergency Department at Southern Maryland Hospital has reduced wait times for patients and costs for the department by setting up a special “Fast-track” area for patients with some of the same kinds of symptoms targeted by the Washington rule.
• More patient education. The gap between what a patient knows and what a trained emergency physician knows is huge. Often times this knowledge gap leads patients to expect a huge amount of treatment and every test possible, when the emergency physician’s best judgment is often something more like, “take two and call me in the morning.” Patient education likely demands a nation-wide shift in culture, but we’ve got to start somewhere.
• More effective treatment for repeat visitors. Like all areas of medicine, research shows a huge proportion of emergency costs are caused by a small percentage of patients, those who come back again and again. Sometimes it’s because these patients are unable to get primary care elsewhere, and other times it’s for less valid reasons, such as to feed an addiction to pain-killers. Electronic records keeping and information exchange can help physicians find and better treat these patients, while the right training for physicians can help them direct patients with addiction find the right treatment outside the emergency room.

The cost-structure of an emergency department, where the facilities, technology, and staff exist to handle the most serious emergencies, is such that it will always be expensive. And yet many departments are tackling the problem head-on using a combination finely-tuned strategies that can both reduce costs and improve care. It’s those kinds of strategies we should be incentivizing – not ones that use a hammer to tighten a screw.