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Washington State Medicaid cuts for ER visits

Discussion in 'Emergency Medicine' started by Jarabacoa, 09.12.11.

  1. yappy

    yappy

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    SDN Members don't see this ad. (About Ads)
    YES! EMTALA needs to be repealed OR make them pick up the tab and put a lean on anything they own or have authority to take a % of their future earnings.

    It is crazy that you must treat someone; yet, they have no responsiblity to pay it back. I can see either getting rid of EMTALA or making it so that any services provided must be paid back over the course of the persons life.


  2. Rendar5

    Rendar5

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    set up a clinical intervention group that looks into anyone on medicaid who comes to the ER 3 or more times in a year and see if anything can be done to reduce their strain on the system, whether it's identifying doctor shopping/prescription abuse and interceding at the pharmacy level, poor access to primary care, a poorly maintained chronic condition (expensive treatments being denied but leading to more expensive ED visits), etc.
  3. sylvanthus

    sylvanthus EM/IM/CC PGY-2

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    Copay at the door.
  4. Jarabacoa

    Jarabacoa non carborundum ilegitemi

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    I love how they offer up several other far left petitions. I accidentally petitioned against an electricity company for..."gasp"... making electricity with coal.
  5. Foster23

    Foster23

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    Can EMRA, ACEP, and large EM societies email the petition to their listserve? I signed, but the count is only at 1200s.
  6. mtwop

    mtwop

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    Signed. What a joke
  7. Hamhock

    Hamhock

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    :thumbup:

    ...when I have some time to read it - I will most certainly sign it.

    Pre-emptive: Done and done. (cooked well - that's for you Ap)

    HH
  8. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    Require a copay. Charge for parking.

    Or, alternatively, punish those that abuse it, not those being abused.
  9. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    Honestly, you got me. I don't get it.
  10. Birdstrike

    Birdstrike

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    Last edited: 08.05.12
  11. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    For this particular problem (Medicaid and other patients using the ER for primary, non-emergent care) EMTALA isn't the issue. These patients are actually excluded from EMTALA because they are non-emergent. EMTALA requires they receive a medical screening exam but that's it.

    The issue here is liability. If you deem them to be non-emergent and you're wrong you have a very high risk situation as EMTALA will pile on with the usual med mal liability. Add that to the fact that once you've done a medical screening exam it's usually easier, faster and more defensive to just treat the patient than to try to deny or defer care.

    The dark secret of EM is that most of us would prefer to just treat the needy. I'd prefer to exclude the well off who are abusing the ED out of convenience. But those are the patients who pay the bills.
  12. GeneralVeers

    GeneralVeers Globus Hystericus

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    What about the universal "right" to healthcare? You would be violating their human rights in not providing free care.
  13. Foster23

    Foster23

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    How will this impact EM residency in Washington State?
    If I have to apply again, I think I would steer away from a Washington state as the passing of this policy will likely throw chaos into the programs. I'm betting a lot of teaching faculties will consider relocating to a more friendly State. For the students out there, would you still consider EM residency in Washington State?

    How will this impact recruitment of EM board certified physician to the state?
    I cannot think of one person that would take a job in Washington state right now other than for family reason.

    I think the impact of this law will be felt immediately. Whether through massive relocation, reduction in recruitment, or chaos in implementing the policy.
  14. WilcoWorld

    WilcoWorld Senior Member

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    I sure hope so.
  15. Birdstrike

    Birdstrike

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    Last edited: 08.05.12
  16. Quirk11

    Quirk11

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    Guys:

    I feel for you, this really is unfortunate. However, with a debt to GDP ratio of 100% we are headed towards Greece (150%). Healthcare used to be 4% of GDP, now its 20%. The government HAS to cut it - there are no choices. Keep in mind the politicians have to get the baby boomers / 40 million immigrants equal "access" in the next 10 years.

    Midlevels are one "answer" for politicians, however that is a small part. We all know they won't save much (ie they bill the same as us). RATIONING has to occur. IPAB, capitation, etc. The politicians know to change fee for service to one time capitation is going to at least help a little bit. That is why private practice is going away already, in my small rural state especially.

    Hospitals have the biggest lobby and even they are not going to be paid as much for medicare readmissions within 30 days. So, I don't know if you guys will be successful.

    IPAB will also be totally reshaping specialties in 5 years (ie is dialysis cost effective, CABG ? , hip replacement, cataract surgery?) We can only hope there will be some level of medical representation like the "NICE" board in the UK..but I am somewhat pessimistic.

    Bird Strike, where are you - maybe those urgent care centers will do well.

    My field has its own problems though, so take heart...

    Keep up the fight but I don't think it is going to be a long term "win" for you guys or any of us that don't want this sort of "rationing" or "payment refusal" scheme..



  17. Rendar5

    Rendar5

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    It's not going to be a long term win because the legislation is going to cost more money than it saves because it doesn't do anything to contain healthcare costs. People will still come ot the ER for "non-emergent conditions" and will still require the expenditure of resources to work them up. It's not rationing, it's passing the buck.
  18. WilcoWorld

    WilcoWorld Senior Member

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    I'm all for rationing.
  19. GeneralVeers

    GeneralVeers Globus Hystericus

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    If they truly want to limit the costs of healthcare, both the government and hospitals need to do several things:

    1. Government needs to define what constitutes a medical screening exam and who can do it. This needs to be in writing.

    2. Tort legislation needs to be passed protecting physicians and hospitals from ANY malpractice claims if the MSE is performed according to regulation.

    3. Hospitals need to allow nurses to perform the MSE at triage. There should be no initial doctor involvement. At the point you involve physicians it essentially becomes an unfunded mandate, and becomes financial unviable for us to turn patients away.

    Simply put, if you are a medicaid, medicare, self-pay (or even insured) patient and you come to the ER, you will get triaged by a nurse who will also fill out the appropriate electronic form during the process. If you are financially triaged, at that point you can choose to pay up-front, out of pocket for the visit, or seek care elsewhere. This may sound harsh, but it's the only thing IMO that will save our system.

    As Medicare/Medicaid get necessarily cut (there is no way around this), their recipients will more and more seek care in the ER as it will be a financial loss for PMDs to see them. We have to start demanding that patients pay more out of pocket for non-emergent care.
  20. Birdstrike

    Birdstrike

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    Last edited: 08.05.12
  21. xaelia

    xaelia neenlet

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    The key statement is in the above - immunity. What other profession is federally mandated to risk their livelihood via litigation while the state reimburses them nothing? There's no incentive to have the hospital malpractice cover an RN doing the MSE unless the liability is nil.
  22. GeneralVeers

    GeneralVeers Globus Hystericus

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    We'll never get immunity. The trial lawyers association owns the Democratic party and will prevent any legislation with teeth from getting through.

    This is the primary reason why single payor system would fail here (not including the other issues of constitutionality, personal choice, or cost). A necessary evil of a single payor system is government rationing and refusal of care. In this country the government could prevent you from getting a CT scan on a headache. If it turns out to be a brain bleed, then you could be sued. Who'd want to work under that system?
  23. xaelia

    xaelia neenlet

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    Someone more familiar with Washington than I would have to look and see how the chart can be massaged with secondary diagnosis codes to prevent it from being labelled a "non-emergency" condition.

    Sort of like, for OP-15 for headache, you can do the CT as long as have a secondary diagnosis that includes:
    lumbar puncture, dizziness, paresthesia, lack of coordination, subarachnoid hemorrhage, complicated or thunderclap headache, focal neurologic deficit, pregnancy, trauma, HIV, or tumor/mass.

    I pretty much just make sure I use 339.4 Complicated headache syndromes or one of the sub-diagnoses if I'm anticipating a CT for headache. Wonder if the same work-arounds will be possible in Washington.
  24. BADMD

    BADMD

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    I don't think anyone denies that. This is set up to deliberate screw EDs.

    Require me to see the patient and perform a MSE...I get it. I don't like it, but I get it. There have been significant abuses in the past and EMTALA is a very blunt way of dealing with that.

    Refusal to pay for non-emergency conditions...I get it too. Broadly it makes sense, although there is a whole lot of stupid involved. This could be done right if it used a lay person standard of emergency.

    Calling it a "covered service" and then preventing EPs from balance billing the patient? FU Washington State. You don't want patients to go to the ED for their sore throat? Well, neither do I. But all this does shift the cost to the EP/Hospital. The patients will continue to seek non-emergency services in the ED as long as they have no skin in the game. At the very least, EPs should be allowed to demand some sort of payment, on the spot, after the MSE, if it is a non-emergency condition.

    I would almost think that the Washington State Medicaid director is trying to punish EDs/EPs.

    Oh wait, he is...
  25. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I don't think it will go down like this. Don't get me wrong I think this policy is horrible. But we've been faced with horrible policies before and it usually doesn't result in the mass migration and work stoppage that it should.

    I suspect that the army of case managers in WA are right now examining the rules (while we panic) and will soon come out with a batch of Byzantine guidelines for documenting on Medicaid patients so that the visits won't be declared non-emergent. We may be looking at a situation where every Medicaid patient gets admitted from now on or has a CT scan or whatever it takes to reclassify them as emergent.

    We should fight. But we won't. We'll figure out how to take as little of a hit as possible and continue on. Look how we dealt with core measures, and PG, and P for P, and restrictions on balance billing.
  26. Birdstrike

    Birdstrike

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    Last edited: 08.05.12
  27. GeneralVeers

    GeneralVeers Globus Hystericus

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    Medical school selects for mousy individuals who will put the interests of others ahead of their own. Most docs have said they just want to "practice medicine" and not get involved in politics or bureaucracy. We've seen the result of this attitude, and it's killing us.
  28. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    This is quite true. Medical education, as it's currently set up, selects for people with science backgrounds rather than legal or political. It then effectively removes these politically naive people from society for about a decade by immersing them in such demanding training that they don't have much time to think of anything else. During that there's always a generous dose of socialism as with any contemporary American higher education. Once out heavy loan burdens and the rigors of the field such as poor reimbursement and constant threat of litigation demand full attention again leaving little time or energy for political activism. In medicine the more you work the more you are isolated to your ED or clinic.

    This is in stark contrast to other fields such as business and law where the more you work the more networking opportunities and visibility you achieve.
  29. Powdermonkey

    Powdermonkey ninja doctor in training

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    What. The. ****? How in holy hell have ED physicians been "abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER,"??? If the state won't pay for it, who is going to? I'm confused by this. And how do we become "better stewards of care and safety and public resources" by cutting reimbursement? I think this douchecano Dr. Jeff Thompson has no actual clue how EDs function.

    If I'm missing a crucial piece of evidence that will explain this to me, please let me know and I'll go read some more. Starting residency in a few months, so the more I can read and learn now, the better.
  30. GeneralVeers

    GeneralVeers Globus Hystericus

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    They need to explain a few things:

    1. How do we LEGALLY turn away medicaid patients

    2. Who assumes the liability for turning them away?

    3. What clinics will the government set up to see them, as most primary docs refuse medicaid?
  31. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    He knows very well how EDs work. You have to remember who his audience is. We know this is BS. He knows it's BS. But the general public will eat this up.
  32. Birdstrike

    Birdstrike

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    Last edited: 08.05.12
  33. DreamingTheLive

    DreamingTheLive (something witty here)

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    As usual, Spot-on. Amazing how such a skilled and talented group can wield so little influence with regards to their own profession and livelihood. When did we become so powerless and such a fractured community of physicians?.....

    (**....leaves EM thread to go to Allo thread and post derogatory comments about other specialties and their physicians**)
  34. Old_Mil

    Old_Mil Senior Member

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    This is the problem. This will never happen on a national scale, and certainly not in any blue state where the politicians are bought and paid for by the trial lawyer lobby. We're about to get the worst of socialized medicine, and the worst of ours dropped into our laps.

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