Washington State Medicaid cuts for ER visits

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What do you guys think about the recent development in Washington State? Apparently, the state is trying to trim the budget. One of their many ideas? Limit reimbursement for Emergency Department visits to 3 "non-emergent conditions" per year.

http://www.wsma.org/files/Downloads/GovernmentRelations/leg_agenda_2011_summary.pdf

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. (Savings of $33.0 million GF-State and $38.8 million other funds)

The rub? Here are the "non-emergent conditions"

http://www.wsha.org/files/65/Non-Emergency Conditions.pdf

Some commentary:

http://www.washingtonacep.org/postings/non_emergent_conditions_letter.pdf

I must be missing something here. Anybody have an explanation from up there in Washington that knows about this?

Could this represent the future of our beloved goal of socialized medicine; simply ratcheting down reimbursement until the budget is met, regardless of need or demand?

What will be the impact on ER collections? How will that impact recruitment to Washington ERs?

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Oh yeah, septicemia isn't an emergency. Urgent care, maybe.
 
Oh yeah, septicemia isn't an emergency. Urgent care, maybe.
Neither is Sickle cell SS crisis or cellulitis. Or cardiac dysrrhythmias NOS. WTF does that even mean? How are you supposed to know when your dysrrhythmia is bad and when it's benign? That's what the ED is for. At least half of the complaints on the list are primary care complaints though, so in a way, I kind of understand it. I just wonder what they're gonna do to all the frequent flyers with medicaid? Start billing them? Do they think they're actually going to pay? It'll make the hospital go broke. And like Jarabacoa said, what about reimbursing the docs?
 
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Ha. Epistaxis (7847) is on there too. That could be a super bad emergency if it's a posterior bleed.
 
Hypoglycemic coma is on the "non-emergent" list

So are status asthmaticus and acute cholecystitis.
 
And pneumonia (Pneumococcal!), renal colic, and headache (including migraine).

Oh, and abdominal pain (all quads). And gastroenteritis. Really? What if the patient is admitted?

From that list, I'm surprised meningitis (viral) wasn't listed.
 
This is what happens when bean counters with a little bit of knowledge try to become experts. It would be comical if it were not true.
 
The only thing that I can figure from that list is it's a master list up for debate/pruning, but that can't be right because there are plenty of ICD codes missing in there. Eek! And I remember the days of the Oregon Health Plan above the line/below the line battles....
I have no qualms telling someone her vaginal discharge can go to the health dept but I worry about screening out the DM and dysrhythmias and potentially scary infections which go from not too bad to serious badness in a day or less. Your sore throat? Not emergent. Oh, you suffocate because it's really Ludwig's angina that has tracked deep into the neck in the last 6 hr? Woops.
 
Could this represent the future of our beloved goal of socialized medicine; simply ratcheting down reimbursement until the budget is met, regardless of need or demand?

It certainly does. Basic economics shows that to socialize you have to ration. This looks like a primordial stab at that.

I am so disgusted with the whole system that I'm fine with them defunding various ailments. So long as they indemnify me from EMTALA and med mal. And we all know that won't happen.
 
I'll second the hypoglycemic coma as my favorite. I guess they figure coma is a stable condition? Some of the ridiculous ones you could get around by calling it something else, ie "sinus tachycardia" instead of dysrhythmia but how they figure pneumonia falls into the category is beyond me. Are we only supposed to consider it emergent if there is associated respiratory failure?

That being said, only paying for 3 ED visits per year for a list of "non-emergent" conditions isn't the most unreasonable thing I've ever heard. How often do most people need to visit the ED in a year?

P.S. Of course I am strongly against anything that cuts reimbursement to the ED.
 
I like the following quote from Kevin D Williamsen:

Socialism's main defects are the inability of political decision-makers to make rational decisions without the information provided by prices generated by marketplace transactions; the misalignment of incentives and resources; and the subjugation of economic necessities to political mandates with no basis in material economic reality. As Mises's colleague F.A. Hayek argued in the Road to Serfdom, central planners frustrated by their inability to mold the economic world to their will inevitably are tempted to run roughshod over the rights and interests of the individuals they purport to serve. Sometimes this takes the relatively innocuous form of high-handed officials in the Canadian public-health service denying a procedure or timely access to care; sometimes it takes one of the diverse forms explored with such horrific vigor by Kim Jong Il.

As soon as Obamacare puts private insurance out of business, government can seize control over the entire industry, socializing it, leading to similar random mandates that have no basis in reality.
 
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I like the following quote from Kevin D Williamsen:



As soon as Obamacare puts private insurance out of business, government can seize control over the entire industry, socializing it, leading to similar random mandates that have no basis in reality.

At least then the proles will be angry at the government rather than us. Do you ever really get mad at the drone behind the counter at the post office as they while away their lives waiting for their pension? I can't wait to be a drone.
 
While the list is obviously screwy, I like the idea of punishing the PATIENT for more than 3 non-emergent COMPLAINTS (not diagnoses) a year. I hope they don't punish the doctor for it, and that they realize that while costochondritis is not an emergent diagnosis, chest pain IS an emergent complaint.
 
i guess the idea is that you shouldn't have sepsis 3x in a year, or whatever... clearly there should be some logic applied here. unfortunately, govt programs aren't known for their logic!
 
Favorites: Septicemia (including staph!), HIV disseminated (dis = disseminated or disease?), mycoses (some can be bad, esp if disseminated), malignant neoplastic prostate, thyrotoxicosis, hypoglycemic coma, HbSS with crisis, paralysis agitans, Bell's palsy (because no one would ever come in thinking they had a stroke...I guess they should know the diagnosis before entry to ED), cardiac dysrhythmias, arteritis, CHF, PNA, COPD acute exacerbation, status asthmaticus, acquired pyloric stenosis, paralytic ileus, anal fistula, rectal/anal hemorrhage, acute chole, renal failure, renal/ureteral/urethral calculi (doesn't say obstructing), antepartum hemorrhage, omphalitis, neonatal hemorrhage, aphonia, chest pain, bacteremia, abdominal mass, tetanus toxoid...wow and so many more!

I think it may be easier for them to put out a list of diagnoses they would include. I guess the biggest things they will have to change is their diagnoses (ex hypoxemia) to get covered and paid. The other thing this list says is that no one should enter the ED unless they know their diagnosis prior to arrival.
 
With the ridiculous list of "non-emergent conditions", there is one thing that is being missed in the debate: EP/EDs still have to see the patients. Sure, Washington State Medicaid isn't going to pay, but then again, it is unlikely the patient will either. The state is just shifting the cost of care on physicians and hospitals.

As much as I want to keep the crap out, EPs need to actively fight savings proposals like these. We will end up eating the costs of care.
 
With the ridiculous list of "non-emergent conditions", there is one thing that is being missed in the debate: EP/EDs still have to see the patients. Sure, Washington State Medicaid isn't going to pay, but then again, it is unlikely the patient will either. The state is just shifting the cost of care on physicians and hospitals.

As much as I want to keep the crap out, EPs need to actively fight savings proposals like these. We will end up eating the costs of care.

Good point.

They want us to be reimbursed in retrospect, but judged in our actions regarding outcomes as if we were prophets. They want us to be pushed to be less conservative and use less resources, while protecting the rights of the individual patient in their quest to sue us out of existence if we are wrong.

AAAAAHHHHH! Look at my post count.
 
With the ridiculous list of "non-emergent conditions", there is one thing that is being missed in the debate: EP/EDs still have to see the patients. Sure, Washington State Medicaid isn't going to pay, but then again, it is unlikely the patient will either. The state is just shifting the cost of care on physicians and hospitals.

As much as I want to keep the crap out, EPs need to actively fight savings proposals like these. We will end up eating the costs of care.

Just like EMTALA. If it worked once, why not again?
 
At least then the proles will be angry at the government rather than us. Do you ever really get mad at the drone behind the counter at the post office as they while away their lives waiting for their pension? I can't wait to be a drone.

As long as I'm still getting paid I can't either. At least then I won't have to worry about customer satisfaction.
 
As long as I'm still getting paid I can't either. At least then I won't have to worry about customer satisfaction.

Interesting that this so commonly comes up with this discussion. I thought the same thing...government progrmas care less about patient satisfaction. However, I'm not sure it is true. Note that CMS reimbursement for hospitals is going to be linked to patient satisfaction in the near future.

I was talking to a doctor the other day who worked in the VA system for several years as a hospitalist. He felt the patient satisfaction obsession was much worse in the VA system. He described numerous instances where he and his colleagues were made to eat crow for things that were ludicrous. While rank sometimes pulled weight, the lowest ranking soldier has the ability to make your life @#!*% as a doctor. He described a patient complaint being taken seriously by administration about a soldier. The soldier got a dermatitis from wearing body armor and wanted a doctor's note to be able to go to combat without body armor. The physician stood by his guns and said no but it was weeks of senseless wrangling before the issue finally got resolved. He describes the insane bureaucracy making him hate his job so much he got out.
 
Just like EMTALA. If it worked once, why not again?

I like to think that EMTALA was based on good intentions and bad acts by hospitals with lots of unintended consequences. This is just a straight up cost dump punctuated with middle finger.
 
IMHO, if this is the way the states are going to begin shifting the cost, we will have become de-facto agents of the government every time we treat government-insured patients. This should provide us, as professionals, the ability to protect our liability in the same way that VA physicians and military physicians are protected - sue Uncle Sam if you can.

Also, The ability for us, as professionals, to deduct our non-paying patients from our taxes would also soften the blow.
 
The state points out that, "the hospital will just have to pay if we don't."

Thanks for clearing that up. lol.
 
IMHO, if this is the way the states are going to begin shifting the cost, we will have become de-facto agents of the government every time we treat government-insured patients. This should provide us, as professionals, the ability to protect our liability in the same way that VA physicians and military physicians are protected - sue Uncle Sam if you can.

Along a somewhat similar line of thought...how about WA hospitals "renegotiate" ED copays with whatever insurance companies WA state lawmakers/workers use. Given the desire of that state to reduce ED visits by reckless cost-cutting measures, it seems only logical that a $500 copay per ED visit would allow policy-wonks to lead by example.
 
How about copays, including the ambulance trip and the ED copay, are deducted from the welfare check? Provides both a source of income to the services, and a deterrent to abuse.
 
What will be the impact on ER collections? How will that impact recruitment to Washington ERs?

This is represents what the standard will be for the future of medicine under Obamacare: restrict reimbursement without providing any malpractice relief. Think CMS and the head CT rules.

You know the medicaid patient population, you know they don't care about their credit scores (assuming the hospital even bothers turning them over to collections), you know that this won't make the slightest dent in how they use the ED...it'll only trim the reimbursement that hospitals receive making Washington hospitals less financially secure.
 
Apparently, hypoglycemic coma is not an emergency either.

...and if a patient comes in with chest pain, and you run all the expensive tests to rule out ACS, PE, etc and end up with "Chest Pain without evidence of ACS" as a diagnosis, they won't pay a dime either.
 
Apparently, hypoglycemic coma is not an emergency either.

...and if a patient comes in with chest pain, and you run all the expensive tests to rule out ACS, PE, etc and end up with "Chest Pain without evidence of ACS" as a diagnosis, they won't pay a dime either.

...as noted by an astute poster in post #5...
 
How about copays, including the ambulance trip and the ED copay, are deducted from the welfare check? Provides both a source of income to the services, and a deterrent to abuse.

Along a somewhat similar line of thought...how about WA hospitals "renegotiate" ED copays with whatever insurance companies WA state lawmakers/workers use. Given the desire of that state to reduce ED visits by reckless cost-cutting measures, it seems only logical that a $500 copay per ED visit would allow policy-wonks to lead by example.

Copays is an interesting issue that I'd like to revisit. So as not to :hijacked: I'll start it as a new thread.
 
In the end, we're smarter than these people... My guess is that physicians will find workaround diagnoses that they can bill for.
 
What do you guys think about the recent development in Washington State? Apparently, the state is trying to trim the budget. One of their many ideas? Limit reimbursement for Emergency Department visits to 3 "non-emergent conditions" per year.

http://www.wsma.org/files/Downloads/GovernmentRelations/leg_agenda_2011_summary.pdf



The rub? Here are the "non-emergent conditions"

http://www.wsha.org/files/65/Non-Emergency Conditions.pdf

Some commentary:

http://www.washingtonacep.org/postings/non_emergent_conditions_letter.pdf

I must be missing something here. Anybody have an explanation from up there in Washington that knows about this?

Could this represent the future of our beloved goal of socialized medicine; simply ratcheting down reimbursement until the budget is met, regardless of need or demand?

What will be the impact on ER collections? How will that impact recruitment to Washington ERs?

It will never last.... The only reason they were able to pull off this cockamamy idea in the first place is because medicaid is jointly funded by the state and the federal govt but managed by the state. Notice they can't do diddly squat about medicare.

This will go to the supreme court if they don't repeal it. If I were a gambling man...wait a minute, I am... I'd bet my remaining medical education debt that it will be repealed. The pitchforks are already in the street...
 
if that list is real, it represents an increadible level of poor judgement bordering on brash ignorance.

acute cholecystitis? septicemia NOS?

man, things aren't looking good.
 
I think it would be fun to turn the tables and create laws that fine legislators for not getting people jobs or not balancing budgets (or simply refuse to pay them when they don't meet criteria).

"Well, your constituents are lazy and didn't even look for jobs but we're still fining you. Thanks for helping us balance our budget.":D

Hey, I think I'm on to something here. We may fix the American democratic process after all...
 
I think it would be fun to turn the tables and create laws that fine legislators for not getting people jobs or not balancing budgets (or simply refuse to pay them when they don't meet criteria).

"Well, your constituents are lazy and didn't even look for jobs but we're still fining you. Thanks for helping us balance our budget.":D

Hey, I think I'm on to something here. We may fix the American democratic process after all...

It's called "elections" and "voting", although I see your point about doing it while they're in office (vs. the only option we have - boot 'em out, after all the damage is done).

And the scumbag legislators would bring the workplace rules into effect, including that you, individually, can't be charged or billed for the cost of damages to facility equipment or business (like if you smash up a company car, or trash a crane, or the like).
 
As an EM Resident applicant, should this make one question attempting to match at University of Washington/Harborview? Will this affect how residents train you believe?
 
Along the lines of costs to patients, do your hospitals charge the ED co-pay if they are in the hospital only as an observation status and not full admission status?
 
I think that we can all agree that something has to be done about Medicaid costs. They use the ER as an expensive primary care clinic. Any suggestions?
 
I think that we can all agree that something has to be done about Medicaid costs. They use the ER as an expensive primary care clinic. Any suggestions?

Repeal EMTALA -->kick them out at the door.
 
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