The expansion of Medicaid (10 million) has reduced the number of uninsured patients, but the number of emergency visits is still increasing.[i]. Contributing reasons: primary care shortages and physicians who won’t accept Medicaid because reimbursements are so low.
- Unless more options are available, it’s unfair to blame Medicaid patients for seeking emergency care. ACEP has urged CMS to increase efforts to improve primary care access for Medicaid emergency patients.
- Emergency department use by Medicaid patients accounts for 4 percent of total Medicaid spending.[ii]
- Emergency physicians are the only doctors required by law to treat Medicaid patients, and they should be compensated fairly.
- State Medicaid programs have sought to limit emergency visits and deny coverage for emergency care. However, all health plans are required by the Affordable Care Act to base coverage on a patient’s symptoms, not the final diagnosis — also known as the “prudent layperson standard.”
Describe the typical Medicaid patient who visits the emergency department.
Medicaid patients are generally as sick as other patients are when they seek emergency care. The majority of Medicaid patients (ages 21 to 64) seek emergency care with urgent or serious symptoms, according to a report from the Center for Studying Health Systems Change.[iii] According to the report, many assessments of “unnecessary” use of emergency care incorrectly look at patients’ final diagnoses, instead of symptoms. For example, it’s not possible for a patient who falls down the stairs to know for sure whether or not he or she has broken an ankle. They need medical care.
Are Medicaid patients inappropriately seeking emergency care?
Medicaid enrollees’ emergency department use accounts for just 4 percent of total Medicaid spending, but because Medicaid enrollees use emergency care more frequently than both privately insured and uninsured persons, state Medicaid programs monitor emergency department use closely (MACPAC 2014).
Higher emergency department use among Medicaid enrollees is explained mostly by the higher rates and more severe cases of chronic disease and disability they experience relative to those who are privately insured or uninsured (MACPAC 2012, Mortensen and Song 2008). High emergency department use also can be a sign of poor access to primary, specialty, dental, and outpatient mental health care in other settings.
Are state Medicaid offices seeking to deny coverage for emergency care or limit visits?
- Some state Medicaid plans, in a shortsighted effort to save money, are denying coverage for emergency visits by setting unfair and unsafe thresholds. State Medicaid directors in Washington State, Tennessee, California, Florida, Illinois and elsewhere have tried or plan to deny coverage without providing alternative places for these patients to get medical care.
- In Washington State, the state Medicaid office sought to deny coverage for emergency care based on a list of 500 final diagnoses the state deemed to be nonurgent, including chest pain and breathing problems. ACEP’s Washington Chapter contended this violated the prudent layperson standard. The state’s Governor suspended the policy.
- Some state Medicaid officials have denied coverage for emergency care, based on misleading results generated by a research tool not designed for that purpose. The tool (an algorithm), created by Professor John Billings of New York University’s Wagner School for Public Service, was developed to evaluate the performance of the primary care system and to assess the effect of interventions to improve access to primary care services. [iv]
- In response to budget crises, state Medicaid officials in many states have sought to deny coverage for emergency department visits based on final diagnosis discharge codes, rather than patient symptoms. For example, a patient with chest pain, a possible indicator of a heart attack, may be discharged with a diagnosis of heartburn, a non-urgent condition. It applies 20-20 hindsight to health care and in the ER that is bad medicine.
How would state cuts to Medicaid affect emergency care?
- Cuts would increase the burden on emergency departments, threatening their ability to meet the emergency care needs of everyone. Emergency departments are required by federal law to provide medical care regardless of whether a person can pay. Reductions would have a double impact on state Medicaid programs because they receive matching federal dollars. Many states have taken advantage of federal program waivers to change coverage and/or eligibility requirements in the wake of continuing state budget deficits.
- When other physicians refuse to accept Medicaid patients because payment rates are so low, patients often have no choice but to turn to emergency departments for care, often after their illnesses become acute. Thirty-one percent of physicians polled by the National Center for Health Statistics expressed an unwillingness to take on new Medicaid patients, compared with 17 percent who didn’t want to accept new Medicare patients and 18 percent who said they weren’t going to accept new privately insured patients. The survey also found that “small practices and, to a certain extent, primary care physicians – had lower-than-average acceptance rates of new Medicaid patients.” [v]
Will cutting Medicaid access to emergency care save money in the long run?
- Patients will continue to need health care, whether in the ER or somewhere else, and all health care has a cost.
- Emergency medical care for all patients — insured and uninsured alike — is just 4 percent of all health care spending in the United States.[vi]
For more information, visit http://newsroom.acep.org.
[i] The New England Journal Of Medicine June 18, 2015. Friedman, Saloner. Hsia. “No Place to Cal Home — Policies to reduce ED Use in Medicaid.”
[ii] MAC facts: Key Findings on Medicaid and CHIP. July 2014. Medicaid and CHIP Payment and Access Commission
[iii] HSC Research Brief. “Dispelling Myths about Emergency Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms.” July 2012. No. 23.
[iv] “Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients,” Centre for Health and Public Service Research, New York University, August, 2006, http://www.ncbi.nlm.nih.gov/pubmed/16815882
[v]“In 2011 Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help,” Health Affairs, August 2012 http://content.healthaffairs.org/content/31/8/1673.abstract