Medicaid cuts target ER visits

Medical services for the poor are eroding in Washington state as budget cuts take hold.

The latest round of Medicaid cutbacks will begin Oct. 1, including efforts to curb repeated use of hospital emergency rooms and similar services at private clinics.

As a financial measure the new rules seem prudent, hospital and government officials say. Medicaid will only pay for three non-emergency visits to emergency rooms per year. Taxpayers won’t be asked to pick up the tab on the fourth or additional trips.

Yet such an approach carries risk.

“We can all agree we need to reduce expenses,” said Dr. Jeff Collins, chief medical officer for Providence Sacred Heart Medical Center. “But you’re asking patients without primary care doctors to self-diagnose.”

Especially worrisome, he said, is that two-thirds of Medicaid patients are children. After the third non-emergency visit to the ER, the state will send a letter to the patient and the family warning them they will be asked to pay for the next such visit. Some worry parents will be less likely to take their children for medical help for fear that they might be billed if the malady is not on the state’s list of emergency problems.

“It’s a very difficult position and one that may put people and children with real medical needs at risk,” said Dr. Darin Neven, an emergency room doctor at Sacred Heart.

Hospitals will likely bear the brunt of the cutbacks. State law requires hospitals to treat anyone who walks into their emergency room regardless of ability to pay. Many of those who repeatedly use emergency rooms for primary medical care have mental illnesses or addictions to pain medications.

Helen Andrus, Sacred Heart’s chief financial officer, estimates there will be more than 4,500 visits to Sacred Heart’s emergency room this year that would have fallen under the new guidelines and wouldn’t be eligible for Medicaid reimbursement.

That equates to millions of dollars in uncompensated care.

The numbers are similar at Providence’s Holy Family Hospital, Andrus said. Officials at Deaconess Medical Center couldn’t be reached for comment, but that hospital’s ER serves fewer patients than both Sacred Heart and Holy Family.

Withholding such payments to emergency rooms will save the state between $34 million and $36 million. That represents about 11 percent of the $300 million in Medicaid cuts needed to meet balanced budget requirements for the 2012-2013 biennium, said Jim Stevenson, a spokesman for the Washington Department of Social and Health Services.

The remaining cuts to help achieve a balanced budget were found by lowering reimbursement rates to hospitals, changing payment methodologies to community health clinics such as the CHAS clinic in Spokane, and dropping benefits for poor adults, such as dental care, eyeglasses, hearing aids and money to help pay for prescription drugs.

Stevenson said the options for cuts were narrow. Federal matching dollars that supplement the state’s Medicaid program include requirements that some services be covered, such as medical and dental coverage for conditions that are ruled to be true emergencies.

State officials and the Washington State Hospital Association had attempted to find a compromise to the Medicaid emergency room funding cutbacks. As solutions proved elusive, the state acted and made its consideration based on budgetary needs rather than medical necessity, Collins said.

Emergency room billing is a complicated scenario. Even though hospitals will be required to continue treating anyone who arrives at the emergency room – and likely write off that cost as charity care – emergency room physicians are independent contractors who would be likely to submit their bills to the patients.

It’s why ER doctors, other physicians and hospitals have been trying to collaborate on the care for Medicaid patients who don’t have a primary care doctor yet need medical attention, said Lee Taylor, executive director of Project Access.

He said there may be ways to set up initial screenings that help direct Medicaid patients who have non-emergency conditions to the right care.

“If we can build a strong network of doctors, we may find a way of providing care consistent with what these patients need,” he said.