ER limits spur worry, action

The state no longer will cover more than three ER visits for Medicaid patients in certain situations.

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WALLA WALLA - A state rule that took effect Saturday limiting emergency room visits for Medicaid patients has health-care officials scrambling for new answers.

On Friday, a group of doctors sued to stop the rule, which limits Medicare patients to three emergency room visits a year for any of 704 diagnoses the state has said are not true medical emergencies.

Those include coughs, earaches, dental pain, stomach and chest pain and early-pregnancy bleeding. Patients will be required to pay for the fourth visit for one of these or other complaints on the list.

This puts patients in the position of trying to diagnose what may end up being life-threatening conditions in some cases, said Monty Knittel, president of Walla Walla General Hospital. "If I have chest pain, I don't have a medical degree, I'm not qualified to know whether that's my heart or indigestion."

That's just one of the reasons the ruling is controversial, noted Linda Givens, the hospital's director of critical care services.

Those living with mental illness will be greatly affected by the new limits, she feels. "They have more problems than most. They have trouble keeping appointments and when they get in crisis mode, they end up in the ER."

In September, state officials notified Medicaid clients of the change. Dr. Jeff Thompson, the program's medical director, said the state's budget crisis forced him to cut at least $35 million a year from funding for ER visits.

It's a move Knittel and others can empathize with. As in every community, there are people here who use emergency medicine as a substitute for regular medical care provided by a primary care physician. "We definitely have some folks we know well," he said.

"It's an extremely expensive way to do that," agreed Alysa Reynolds, emergency department supervisor at Providence St. Mary Medical Center.

Unlike some areas, Walla Walla has physicians with space in their practices for Medicaid patients, she said. "But there is no financial incentive for (patients) to seek care elsewhere."

The Washington State Hospital Association appreciates the state's goal and shares it, the organization said in a statement. However, the benefit limit is not a reasonable approach - the "non-emergent diagnosis" list contains many emergency conditions such as chest pain, women having miscarriages, and children who are ill and in pain.

If a patient comes in for a fourth visit with chest pain, it will be up to the hospital to prove a diagnosis of heart attack in order to bill Medicaid, Reynolds said.

Other states and groups will watch to see how this rule plays out, Knittel believes. In the meantime, WWGH and St. Mary are mandated by law to accept all emergency patients, regardless of ability to pay. "The fourth visit comes to us and we won't get paid for it. All that does is drive up the cost of health care for paying customers."

Walla Walla officials, from public health to crisis response staff, have responded to the situation with a community-wide partnership formed to educate the most frequent abusers of emergency medicine.

The group has met three times so far to ponder a united front, Reynolds said. The multipronged approach will include notifying Medicaid patients of their current number of non-emergency visits to the emergency department, educating people on what is a true emergency and getting people lined up with primary-care physicians, Reynolds said.

Also included is a creating standardized rules surrounding narcotic prescriptions for chronic pain, Knittel said.

"We've endorsed those rules. That was a big step. We don't refill (pain medication) prescriptions, we don't write new ones for lost prescriptions. The goal is to get them back in touch with their primary-care physician," he said.

"But if you come in with a fractured arm, your pain is going to be managed."

Staff at her hospital will help Medicaid patients better manage their health themselves, Reynolds said. "If you come in with a cough, we'll ask if you've tried a home remedy like Robitussin."

Merging the state's expectations with what people have become accustomed to will take time, she added. "It will be a dance at first. Back and forth."

Sheila Hagar can be reached at sheilahagar@wwub.com or 526-8322.

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