Doctor-supported ED access plan gains ground in Washington state

The breakthrough occurred when the governor suspended implementation of a "zero visit policy" that would have withheld Medicaid payment to emergency departments for nonemergent situations.

By Charles Fiegl — Posted April 16, 2012

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After a long legislative and legal battle with emergency physicians, lawmakers in Washington state have turned their attention to an alternative plan supported by ED doctors to prevent overutilization of emergency services by Medicaid patients.

Gov. Chris Gregoire, a Democrat, announced that she was suspending a policy to restrict Medicaid payments to emergency departments for more than 400 patient conditions, which would have included treatment for certain burns, strains and other injuries that were deemed not medically necessary in an emergency setting. The policy was set to go into effect April 1. The state was intending to push Medicaid patients to seek treatment for such injuries in a doctor’s office by denying payment for care if it were received in the ED, where costs to the state are higher.


Gov. Chris Gregoire

In conjunction with Gregoire’s decision, the Legislature was considering at this article’s deadline an amendment to the state’s “zero visit policy.” State officials expected the amendment, which the American College of Emergency Physicians and local doctors support, to pass and receive the governor’s approval.

The alternative approach to discourage unnecessary ED use is written by physicians and seeks to decrease utilization without limiting access to needed emergency care for patients, said Nathan Schlicher, MD, the Washington ACEP’s legislative chair. “We need to get back to solving these problems and not just pass the buck.”

The Washington Health Care Authority, which runs the state’s Medicaid program, spent nearly $98 million on more than 325,000 fee-for-service Medicaid emergency department visits in 2010. The Legislature had estimated that the state could save $35 million a year by limiting what was considered nonemergency care under the zero-tolerance policy.

But physicians opposed such an approach. The American Medical Association sent letters outlining concerns about the policy to the Washington House of Representatives and the Centers for Medicare & Medicaid Services. Physicians and hospitals effectively would be forced to provide free health care because of the ethical obligation and moral responsibility to care for patients regardless of their ability to pay, wrote AMA Executive Vice President and CEO James L. Madara, MD. The state policy also conflicted with long-standing practices and guidance, such as the 1986 Emergency Medical Treatment and Active Labor Act.

“While we understand the budgetary pressures that Washington and other states are currently facing, balancing the budget through a ‘zero visit policy’ is a flawed approach,” Dr. Madara wrote in a March 16 letter to CMS. “Relying retrospectively on a discharge diagnosis to determine the emergent nature of a condition contradicts the prudent layperson standard, which is the predominant standard in EMTALA regulations, federal Medicaid managed care law, and many state Medicaid statutes and regulations.”

For instance, an emergency department would be required to screen and stabilize a child with a swollen arm after a playground accident. The hospital and physician would not be paid for the services if the injury were later determined to be a sprain, but they would receive payment under the state Medicaid policy if the arm were broken, the AMA said.

The prudent layperson standard requires health plans to base coverage on a patient’s symptoms and not their final diagnoses. “Patients should never be forced to self-diagnose themselves out of fear that their emergency visit won’t be covered,” said ACEP President David Seaberg, MD.

The state ACEP chapter successfully sued Washington state to block an initial ED access plan, which would have stopped Medicaid pay after three nonemergent visits to an emergency department but that included a broader list of applicable diagnoses. The state responded to the injunction by reducing the size of the no-pay list but also establishing a zero-tolerance pay policy. Further negotiations between physicians and policymakers failed to produce a breakthrough until just before the April 1 policy was to take effect.

The alternative proposal supported by physicians aims to reduce trips to the emergency department by better care coordination, said Dr. Schlicher, who is associate medical director at St. Joseph Medical Center in Tacoma, Wash. The proposal supports case management work for patients with multiple comorbidities, a prescription drug monitoring program, ED utilization tracking, and coordination with primary care physicians to establish a 72-hour follow-up care policy.

“Our goal is to have the plan implemented by July 1,” Dr. Schlicher said.

The AMA sent a March 6 letter to lawmakers in support of the budget amendment. Physicians believe the amendment would yield savings by relying on implementing best practices across the state. If hospitals adopt care coordination, prescription drug monitoring and other requirements, the Washington Health Care Authority would not implement the zero-tolerance policy, according to the proposal.

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Washington state’s list of nonemergencies

The state was set to enforce a policy prohibiting payment to emergency departments for treatments of nonemergent injuries or illnesses starting April 1, but the governor suspended implementation. The state had created a list of about 440 diagnoses considered not medically necessary for ED care, including several that doctors said a prudent layperson could have suspected were emergencies:

  • Contusion
  • Erythema or first-degree burn
  • Local skin infection
  • Headache
  • Insect bite
  • Sprain and strain of ankle, knee, hip, shoulder, elbow or wrist
  • Urinary tract infection

Source: Washington State Hospital Assn. Bulletin Details, Medical Emergency Room Visit List, March 15 (link)

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