Jay Kaplan To John Kennedy, Louisiana State Treasure

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Jay Kaplan To John Kennedy, Louisiana State Treasurer

Sent in reponse to: We can reduce our Medicaid costs

June 15, 2016
The Honorable John Kennedy
Treasurer, State of Louisiana
900 North Third Street, 3rd Floor, State Capitol
Baton Rouge, LA  70804

Dear Mr. Kennedy:

As president of the American College of Emergency Physicians (ACEP), the largest medical specialty society representing emergency medicine, and a practicing emergency physician in New Orleans, I’m writing to take issue with the statements you made about emergency patients in your recent editorial “We can reduce our Medicaid costs.” While I agree with the need to reduce health care costs, many of your comments about why people are seeking emergency care are inaccurate, promote myths and unfairly blame patients. As one of our state’s highest elected officials, it also concerns me that you may discourage some people from seeking emergency care who really need it. The results could be tragic.

Until policymakers provide real options for Medicaid patients to get medical care, it is wrong to blame them for seeking emergency care. Many Medicaid patients are unable to find physicians to care for them, mostly because Medicaid pays so poorly. They also tend to have more complicated and serious health conditions. Emergency departments are the one place that anyone can get care, regarding of ability to pay. 

A report by the Center for Studying Health Systems Change found that most Medicaid patients seek emergency care with urgent or more serious symptoms, most likely because they wait until their medical conditions worsen. The reality is, these emergency patients account for just 4 percent of total Medicaid spending.   

Unfortunately, state Medicaid offices have focused on limiting emergency visits and denying 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.” For example, it’s not possible for a patient who has indigestion to know for sure whether he or she is having a heart attack.  That is care only an emergency department can provide.

You cite Washington State as an example of reducing emergency department use. The history is more complex than you suggest. Before state policymakers began working with the state’s emergency physicians, the Washington State Medicaid office was seeking 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. Emergency physicians in Washington State took issue with this effort and explained how these symptoms indicated medical emergencies and contended that this policy violated the nation’s prudent layperson standard. As a result, the governor at the time suspended the proposed policy. 

It was a bad direction for the state of Washington to go in and it will be bad for the state of Louisiana and any state in this country to keep people who have few or no options for medical care out of emergency departments. This points to the need for partnerships between policymakers and physicians. I encourage you to include emergency physicians in your efforts to reduce health care costs in your state.

The facts show the vast majority of all emergency patients (96 percent) seek emergency care appropriately, according to the CDC. They are not — as you say— showing up in large quantities simply for “Band-Aids, aspirin,” stomach aches, depression, back aches or pimples.” The emergency patients we see are more likely to have severe abdominal pain, chest pain, symptoms of a stroke, mental health issues that require special care and serious injuries that require immediate attention.  These are just a few examples.

The expansion of Medicaid may have reduced the number of uninsured patients, but it is increasing the number of emergency visits. If you really want to reduce the number of Medicaid visits to emergency departments, find a way to increase the supply of primary care physicians and other office-based doctors who are willing to accept Medicaid insurance.

It seems like a simple solution to prevent emergency visits and decrease cost — put a “moat” around the emergency department — but the reality for millions of Americans — including many in Louisiana — is not that simple. 

If you would like to talk further about this, I would be happy to do so. Please contact Mike Baldyga in ACEP’s Public Relations office in Washington, D.C. at (202) 370-9288.


Jay Kaplan, MD, FACEP
President, American College of Emergency Physicians