Medicaid change concerns local physicians

‘Not medically necessary’ emergency visits will not be paid for by the state

By Marissa Harshman, Columbian health reporter

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State Medicaid officials have announced the program will stop paying for any medically unnecessary visits to emergency departments in an effort to cut costs.

The Washington State Health Care Authority -- which oversees Medicaid and six other health care programs -- will no longer pay for care it deems as “not medically necessary in the emergency room setting,” even if the patient believes they are having a medical emergency.

The state created a list of 500 conditions it will not reimburse emergency rooms for treating. That list includes things like asthma attacks and hypoglycemic coma, which, in some cases, could in fact be emergencies, said Dr. Michael Albrich, medical director for emergency services at Legacy Salmon Creek Medical Center.

“The concern we have is this essentially does away with the prudent layperson notion of determining what is an emergent condition,” Albrich said.

Jim Stevenson, spokesman for the Health Care Authority (HCA), said the state isn’t changing its advice to patients. If people are experiencing a medical emergency, they should call 911 or go to an emergency room, he said.

“Now we’re simply saying we will no longer reimburse for services not medically necessary in emergency rooms,” Stevenson said.

Medicaid provides medical care for low-income adults and children. The new policy applies to adults and children on Medicaid, with no exceptions, and is scheduled to go into effect April 1.

Patients who arrive at emergency departments with medically unnecessary cases should be directed to their primary care provider, Stevenson said. If the emergency department treats those patients -- even if the primary care provider is closed or the patient doesn’t have an assigned doctor -- the medical center will be responsible for the cost. Patients cannot be billed, according to the Health Care Authority.

And in some non-emergent cases -- when Medicaid patients don’t have a managed health plan -- the HCA said it won’t pay for the screening and evaluation needed to determine whether an event is an emergency or not. In those cases, the hospitals will foot the bill for the services, which could include X-rays or other tests.

The problem, Albrich said, is federal law requires hospitals to evaluate all patients who walk through the emergency department doors.

The policy change is the latest and, according to Albrich, most draconian attempt to cut costs.

The HCA initially planned to limit Medicaid patients to three non-emergency visits per year. A Thurston County Superior Court judge halted the implementation of that plan in November, ruling the HCA didn’t follow proper rulemaking procedures.

Rather than go through the procedures for the rules, the state decided to stop paying for all non-emergent visits -- a move that doesn’t require any additional action.

Stevenson said the new policy is in line with Medicaid rules in other settings that require patients receive care medically necessary for that setting. The policy is still a work in process, and HCA officials are still talking with physicians and hospital staff, Stevenson said.

The Health Care Authority estimates the policy change will save the state and federal government $51 million over the current biennium.

“This is another -- unfortunately, another battle I think we’re going to have with the HCA,” said Dr. Marty Bell, director of emergency medicine at PeaceHealth Southwest Medical Center.

The policy change is the second HCA decision in recent weeks to draw criticism from the Clark County medical community.

Last month, the Health Care Authority selected five health insurance plans that appeared to have successfully bid to provide Medicaid services to Washington residents. Columbia United Providers, a Vancouver-based group that currently provides Medicaid health plans to 47,000 Clark County residents, was not selected.

Without Columbia United Providers (CUP), those local Medicaid patients would be assigned new health plans and, in many cases, new primary care providers.

Albrich and Bell said they are in contact with CUP officials weekly. Together, they monitor people who frequent emergency rooms and help connect those patients with primary care doctors, Bell said.

That coordination helps reduce emergency room visits and costs, Albrich said.

“There are many insurers for patients that come to the emergency department, but only CUP bends over backwards to work with (emergency department) directors to create alternatives for people that are lower cost,” Albrich said.

“I think the HCA has been penny wise and pound foolish,” he added.

Emergency physicians across the state, backed by the Washington State Medical Association and Washington State Hospital Association, are lobbying legislators to stop HCA’s policy change.

“It’s unfortunate that HCA has targeted emergency department visits and they appear to be doing it in a way that doesn’t consider the broader scheme of things,” Albrich said.

Marissa Harshman: 360-735-4546; http://twitter.com/col_health;http://facebook.com/reporterharshman;marissa.harshman@columbian.com.