Last week the Washington State Health Care Authority (HCA) issued a press release about a new policy. Starting October 1, the state's Medicaid program will limit recipients of this health care coverage for the poor to three visits per year for problems that turn out not to be emergencies. After they reach that limit, Medicaid won't pay, and the patient may be billed.
Any time a government agency decides to do something new, it may be instructive to ask what problem it is intended to solve. It seems the folks at HCA have decided Medicaid recipients are visiting the ED for problems that are not emergencies so often that the state can save a lot of money by imposing restrictions.
The second question I always ask is whether the agency making the rule is aware of the Law of Unintended Consequences. Let us imagine that a Medicaid recipient is concerned about exceeding the limit and therefore develops a reluctance to seek care in the ED for something that might prove not to be an emergency. The articles in the newspapers say chest pain that turns out not to be a heart attack isn't an emergency. Gee, the person thinks, this is probably just indigestion. Half a day and a full bottle of Maalox later, it turns out it was a heart attack after all, and now there has been enough damage to the heart muscle to weaken its pumping function to the point that the patient will, for the rest of his life, have congestive heart failure. Guess what single diagnosis accounts for the largest number of dollars spent by government health insurance programs? You guessed it: congestive heart failure. Penny wise and pound foolish? You make the call.
Sometimes government agencies make rules without considering the possibility that they are illegal. In years gone by, many of us in emergency medicine worried about patients' reluctance to seek ED care for fear their insurance companies would decide after the fact they didn't have real emergencies and refuse to pay the bills. We successfully lobbied state legislatures, starting with Maryland, for the enactment of something called the Prudent Layperson standard: if a prudent layperson would think symptoms might represent a medical emergency, an insurance company must pay. As it turns out, the federal government has applied the prudent layperson standard to the Medicaid program, which is jointly funded by Uncle Sam and the states. So Washington's list of non-emergency conditions would appear to be in violation of federal law.
There are some unintended consequences that seem quite obvious immediately. The letter sent to Medicaid beneficiaries says that it won't count against your three-per-year limit if you are brought to the ED by ambulance. My friends in EMS are going to be apoplectic over that one. They already get far too many calls for patients who could have gone to the hospital by private vehicle. Now they can expect to be called by patients who want to avoid getting bills for ED visits when it is decided, in hindsight, that they didn't have an emergency. How will that affect the savings anticipated with this new rule?
There is also an exception if you are hospitalized and ultimately diagnosed with a condition on the list. Imagine you are the patient with severe pain from a kidney stone at 5 AM. The emergency physician tells you that's what you have. If she can get your pain and nausea under control, you should be able to go home. If not, you should stay in the hospital. An hour later she's back to ask how you're doing. You feel a lot better, but maybe the pain will come back. Oh, and by the way, if you go home, the bill will be your responsibility, because kidney stone is on the list.
It took a bit of a search on the Web, but I was able to find the list. I was interested to see what kinds of conditions might be there that I think are legitimate reasons for ED visits but commonly do not result in hospitalization. (Oh, and they should also be things that wouldn't necessarily require ambulance transportation. So I'm not counting coma from low blood sugar, because we can often fix that and let the patient go home, but patients in a coma really should come in by ambulance. What were they thinking when they put that on the list?) Chest pain that turns out not to be something serious? On the list. Asthma attack that you can't break with the medicine you have at home? It's on the list, so don't let your husband drive you to the hospital. Call 9-1-1. Nail stuck in your foot? Can't get it out, even with pliers? Yep, it's on the list. (Someone in Olympia thinks your primary care doctor can handle that in the office. An interesting delusion.) Twisted your ankle? It looks bad, but if it turns out you didn't break it, the bill will be all yours. Pregnant? Cramps and bleeding? Think it's a miscarriage? You guessed it - it's on the list.
Dr. Jeff Thompson, chief medical officer for Washington state's Medicaid program, has no use for those who question what's on the list. "I don't have time to engage in silly arguments like that," he said.
Maybe if, instead of complaining about not having time for that, he had taken some time to think about rational solutions to the problem, he wouldn't find himself having to dismiss serious concerns as silly arguments. He says 3% of the state's Medicaid beneficiaries are the ones wasting health care resources in this fashion. How about addressing that 3%? How about patient education and case management for those folks?
You see, if you just say you won't pay the bills any more after three visits for things on the list, the hospitals may or not send bills to the patients, but whether they do or not, they will collect very little (if any) money. And the behavior of the patients who are wasting health care resources will change very little (if at all).
Oh, and if you read the news accounts, you find out just what Dr. Thompson's biases are. He clearly thinks those 3% of patients are mostly visiting EDs to get prescriptions for narcotics. I think someone who is so harshly judgmental about the people his agency is supposed to be helping should find himself another line of work.
No comments:
Post a Comment