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Medicaid To Limit Emergency Room Visits

Ruby de Luna

Starting October 1, the state is going to crack down on ER visits. Medicaid has come up with a list of 700 medical conditions that it considers non–emergency. As KUOW's Ruby de Luna reports, the state will only pay for three non–urgent visits a year.


Each day, about 170 patients come through the emergency room at Tacoma's St. Joseph Medical Center. They come here for a variety of reasons.

Dr. Nathan Schlicher: "Chest pain, abdominal pain, dizziness and stroke are probably our big four hitters and they're all on the list in one form or another."

Dr. Nathan Schlicher is an ER doctor here. He says about a third of the patients they see are on Medicaid. The list he's referring to is the 700 medical conditions that the state deems non–emergent. He doesn't dispute that a condition like toe fungus is not critical, but let's say a patient comes in with chest pains and the doctor determines it's not a heart attack. Under the new policy, chest pain is considered non–emergent.

Medicaid will allow three visits like this. But the fourth one — the patient is on the hook for that.

Schlicher takes issue with the new policy.

Schlicher: "If you have chest pains, just because you're not having a heart attack doesn't mean it wasn't an emergency. We should be thankful that's not the case. When you come in short of breath and you have an asthma exacerbation and we're able to fix that in the emergency department and get you home and save health care as a system a lot of money, that should be a victory."

Schlicher says the new policy forces people to self–diagnose. Worse, he says, people will stop seeking medical care when they're sick and need it.

The state came up with the new rule as a way to save money — an estimated $70 million. It also created some exemptions. For example, foster kids or patients who come by ambulance won't be affected. But there's another issue the state is trying to address.

Dr. Jeffrey Thompson: "Many of these people are actually using the emergency room for their narcotics."

Dr. Jeffrey Thompson is chief medical officer for Washington state's Medicaid program. According to state data, patients often go to the ER for nonspecific complaints: headache, migraines, abdominal pain and chest pain.

Thompson: "Those are the four diagnoses that are the top of the list that have the most frequency of visits and the most frequency of narcotic prescribing out of the emergency room. Is this the best we can do? Some of these people go 100 times a year – a hundred times. So where do you draw the line?"

State data also shows that the more often a patient goes to the ER, the more likely they're abusing pain medications. But some ER doctors, like Nathan Schlicher, say the policy goes overboard.

Schlicher: "When we look at drug abuse and things like that inside the Medicaid program, they're .2 percent or less of the Medicaid population, yet this policy is going to affect 10 times as many patients. Let's not punish good people who are doing the best they can in a difficult situation and a difficult economy."

There's no disagreement that the number of people seeking narcotics is a small fraction of Medicaid clients, but the state says the problem is costly and unsustainable at a time when people are being turned away for services like basic health and disability lifeline.

Some hospitals have come up with policies to deal with people who go to ER's specifically looking for drugs. But Thompson says there's no consistency since guidelines differ from hospital to hospital in Washington state.

Thompson: "We are in the top 10 of prescription–related narcotic deaths in the United States, and Medicaid clients bear the brunt of that. Half of the deaths come out of the Medicaid population."

Thompson hopes the new policy will change people's behavior. He says on average most Medicaid patients go to the ER no more than twice a year.

Limiting ER visits may save money in the short term, but it doesn't address the underlying problem, says Aaron Katz. Katz is principal lecturer at the University of Washington's School of Public Health. He says people are going to emergency rooms in part because they don't have access to the appropriate type of care whether it's primary care physicians, dentists or mental health specialists. By law hospitals can't turn away patients regardless of their ability to pay.

Katz: "If they're on Medicaid and the state isn't going to pay, then that cost is going to be absorbed by the hospital, which means everybody else who pays for hospital care pays. That means insured people pay more, taxpayers pay more, everybody pays more."

The state is going to monitor how the Medicaid ER visit cap plays out. Officials say they plan to meet every other month with hospitals and emergency room doctors to find out if adjustments need to be made.

I'm Ruby de Luna, KUOW News.

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