Medicaid-ER policy gets new look

Washington had been sued over a policy that limited patients' visits to the emergency room.


After vehement backlash and a lawsuit by the medical community, the Washington state Legislature is once again looking at Medicaid-paid visits to hospital emergency rooms.

In October, a state rule took effect that limited emergency room visits for Medicaid patients to three non-emergency trips.

However, the idea did not go over well with hospitals and health care providers, noted Jim Stevenson, a spokesman for Washington state Medicaid. "They actually sued us."

The list of what would not be considered medical emergencies was long, starting with earaches and dental pain, moving to early-pregnancy bleeding and chest pain.

Doctors and others worried the new rule would put patients in the position of trying to diagnose what could end up being a life-threatening situation.

The concept was part of an effort to trim $35 million from the state funding for ER visits, program officials said last year.

In November, a Thurston County Superior Court judge ruled against the state Health Care Authority on the grounds that proper procedure in implementing the rule was not followed, Stevenson said Thursday.

"We went back to the drawing board and devised a different system that (put in place) what we paid for had to be medically necessary."

Again, there was "widespread dissatisfaction" in the health care community, he added.

A third attempt to find balance between good medical care and misuse of emergency rooms on the taxpayer dime is enjoying better success so far and is slated to take effect on July 1.

The new plan -- included in the Supplemental Budget passed April 11 by the Legislature -- has been a collaborative effort by the American College of Emergency Physicians, Washington State Medical Society and Washington State Hospital Association to agree on ways to better manage emergency department services and prevent misuse.

"The Legislature authorized us to work together on best practices that hospitals will be committed to," Stevenson said. "The plan depends on hospitals and doctors to help identify systems and procedures that will reduce the use of emergency departments by referring non-emergency patients to more efficient and effective levels of care."

The new proposal is "absolutely" OK with her, said Alysa Reynolds, emergency department supervisor at Providence St. Mary Medical Center. "This is physician and health care provider-driven."

There is no argument from providers that ER medicine attracts inappropriate use and abuse, she said. For example, "We are not here to manage chronic pain," Reynolds noted.

One part of the latest plan is an "information exchange system," an electronic way to track where people are seeking emergency room care, Reynolds pointed out. "If someone comes here, then goes to (Walla Walla) General, then Kennewick, we will see that information. We'll have that information and help them better manage that condition."

The electronic system will also help identify drug or painkiller seekers, according to the HCA's press release.

The July 1 proposal is awaiting formal commitment from hospitals. It calls for continued collaboration, establishing feedback reports to the state, patient referral within 72 hours and patient education.

And always, clients will be advised to call 911 or go to an emergency room if they believe they are experiencing a medical emergency.

"Overall, this is going to be a benefit to patients and the community and reduce the amount of Medicaid dollars spent inappropriately," Reynolds said.


Use the comment form below to begin a discussion about this content.

Sign in to comment

Click here to sign in