government

Judge halts Washington state Medicaid limits on ED visits

State officials plan to conduct a new rulemaking process with public comment in an attempt to implement the limit again in 2012.

By Alicia Gallegos — Posted Dec. 5, 2011

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In a victory for Washington state doctors, a judge has blocked a rule limiting Medicaid enrollees to three emergency department visits a year for conditions the state deems nonemergent.

Physicians said the rule compromised patient safety because the list of noncovered conditions included potentially life-threatening ailments, such as chest pain and breathing difficulties.

Debate about the issue is not over. The state says it will continue to push the coverage limit through another rulemaking process.

"The judge's order was entirely procedural. It did not deal with the limit or the rule itself," said Jim Stevenson, spokesman for the Washington State Health Care Authority, the state's Medicaid agency. "We will redo the procedure, fulfilling the requirements" ordered by the judge.

The emergency department coverage limit stemmed from a legislative mandate to reduce unnecessary ED care for Medicaid enrollees by $70 million during the next two years. The savings were built into a budget that Washington state lawmakers adopted in the spring.

Starting Oct. 1, the health care authority planned to stop payment for Medicaid enrollees' fourth and subsequent ED visits for nonemergencies within a single year. More than 700 conditions were classified as nonemergent, such as sunburns and diaper rashes. The Washington chapter of the American College of Emergency Physicians agreed to a list of 200 nonemergent conditions but rejected the more expansive state list.

On Sept. 30, the ACEP chapter sued the state, seeking to overturn the rule. Other state medical and hospital societies joined the lawsuit, including the Washington State Medical Assn.

In her Nov. 10 opinion, Thurston County Superior Court Judge Paula Casey said the state had not followed proper rulemaking standards in implementing the regulation. The judge ordered the state to go through a new process before enacting the limit, including public hearings and comments.

Doctors relieved at ruling

The state medical association was pleased with the ruling, calling the coverage limit dangerous. Physicians worried that poor patients would stay away from the ED during legitimate emergencies for fear of being stuck with a large hospital bill.

"The state's process has been arbitrary and capricious, and stopping it was clearly the right thing to do," said Nathaniel Schlicher, MD, legislative chair for ACEP's Washington chapter. "We continue to be interested in a truly collaborative process to reduce unnecessary emergency room visits. We will not, however, stand by and allow a policy damaging to Medicaid enrollees to take effect."

Physicians and hospitals plan to work with the state with the goal of crafting an effective but fairer policy on unnecessary emergency department use, said Scott Bond, president of the Washington State Hospital Assn.

The ruling delays the state's ability to save money as the Legislature intended, said Stevenson of the state Medicaid agency. He anticipated that the new rulemaking process will take about six months, and that the state would start saving the necessary funds by next year.

The Washington ACEP chapter is hopeful that doctors and the state can arrive at a compromise on the rule before then, said Shannon McDonald, the group's executive director. The chapter is working on an alternative plan that aims to track patients who are abusing ED privileges, she said.

"We're hoping we can really influence them in the rulemaking stage," she said. "If we are unsuccessful, we will re-evaluate what the policy is and look at our legal and legislative options."

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ADDITIONAL INFORMATION

Case at a glance

Can Washington state's Medicaid agency limit enrollees to three emergency department visits a year for nonemergencies?

The Thurston County Superior Court says no -- for now. The court blocked the limit imposed by the Washington Health Care Authority until the state conducts a new rulemaking process, including public hearings and comments on the rule. The state plans to fulfill the judge's requirements and enact the rule by next year.

Impact: For the time being, Washington physicians and hospitals say Medicaid patients experiencing potentially life-threatening conditions will not need to worry about being denied coverage for ED visits. The Washington State Medical Assn. and other health professionals plan to work with the state to reach a compromise on the coverage limit.

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