Washington doctors decry new emergency care coverage limits

Washington state's plan to limit Medicaid enrollees to three emergency department visits a year for conditions it deems nonemergent has upset physician and hospital associations in the state, which say the agency's definition of a nonemergency is too broad.

The Washington State Health Care Authority -- the state's Medicaid agency -- is fulfilling a legislative mandate to reduce unnecessary ED care for Medicaid enrollees by at least $70 million over two years. The savings are built into a budget that state lawmakers adopted in the spring.

Following the mandate, the Medicaid agency plans to deny payment for Medicaid enrollees' fourth and subsequent ED visits for nonemergencies within a single year beginning Oct. 1. The agency is classifying more than 700 conditions as nonemergent, such as sunburns and diaper rashes.

The Medicaid agency is targeting the estimated 3% of Medicaid enrollees who seek certain prescription drugs by visiting hospitals dozens of times each year and complaining about nonspecific ailments, said Jeffery Thompson, MD, MPH, chief medical officer for the state's Medicaid program. The state will track patients' hospital visits electronically.

But the list of noncovered conditions also includes potentially serious problems such as chest and abdominal pain and breathing difficulties, according a Sept. 13 joint release by the Washington State Medical Assn., the Washington chapter of the American College of Emergency Physicians and the Washington State Hospital Assn.

"It has a potential to be devastating," said Nathan Schlicher, MD, a Washington ACEP board member. "Those are the things we see every day in the ER." The policy will discourage Medicaid patients who are not trying to take advantage of the system from seeking care, which could lead to serious illnesses or even death, he said.

The state's major physician and hospital organizations agreed to restricted pay for about 200 of the diagnoses, but this list would have saved the state only $10 million, said Shannon McDonald, MD, Washington ACEP's executive director.

The medical societies are overstating the danger to patients, Dr. Thompson said. Patients who have chest pains with cardiac origins will be covered. The state also will cover hospital visits for patients who later present with emergency indications, patients admitted to the hospital, and those who arrive at the hospital in a police vehicle or ambulance, he said.

"Any implementation with anything this big, there may be unintended consequences," Dr. Thompson said. He expressed interest in working with the medical community to respond to those concerns completely.

The agency's full tally of 700 nonemergent conditions is based on a list developed by researchers at the New York University Center for Health and Public Service Research. The authors classified a list of conditions by their appropriateness for ED treatment. But Dr. Schlicher said hundreds of diagnoses on the NYU list were classified as emergent and do not belong on a list of nonemergent conditions.

The Washington state agency's policy has the potential to erode the prudent layperson standard developed in federal and state law, according to the medical societies' joint release. This standard requires health plans to cover visits to EDs if they are based on a person's reasonable belief that he or she may be suffering a medical emergency due to the symptoms being experienced, not based on a final diagnosis.

Dr. Schlicher said the medical societies could pursue legal action against the state if it implements the ED coverage restrictions as planned.