Washington State DSHS To Limit ER Visits -- How will that work out in reality?

[jmj11]

The Washington DSHS is considering a money saving act to limit "non emergent" visits to the ER to three a year. If the patient goes more than that, they will not be covered. They have listed non-emergent to "blisters, headaches, chest pains and etc." I was just wondering how you think this will work out on the ground? I mean, I see the logic, but trying to decide if chest pain is nonemergent verses emergent will be difficult on paper.

[taotaox1]

Chest pains are seriously listed as non-emergent? What idiot is in charge of this?

[jmj11]

Here is the press release about it:

 

http://www.seattlepi.com/news/article/Wash-to-limit-Medicaid-emergency-room-visits-2189394.php

[Contrarian]

Sort of like now how many third-party-payers will only pay for the ambulance ride IF the policyholder is admitted to the hospital. Thing is... the patient or patient's family, as lay persons without any medical training, didn't know if the problem was a emergency or not. A perfect and classic example of this is minor head/facial Lacerations that may only require 4 sutures but BLEEEEEEEEEEED so profusely that anyone without medical training thinks the patient is hemorrhaging to death. So they call a ambulance, get a ride to the hospital, sit there for 6hrs (cause we know it ain't really a emergency), Then the provider tosses in 4 sutures, sends them home, and a month later... they open the mailbox to a $3,000 bill.

:sadface:

 

Its silllinesss...

 

Basically they are saying that they simply will not pay for more than three (3) ED visits a yr.

 

So now the providers who want to remain out of the NPDB will still have to diligently work up ALL presenting complaints (to avoid a MP suit), but it will be a crap-shoot on whether the facility will be paid for the encounter or not.

 

The only plus to this is that this should equate to more PA-Cs being hired by hospitals... the downside is that it will only be in "Fast-Track"... and all of these "Urgent Care/Triage" PAs will be walking around holding themselves out as "Emergency Medicine/Emergency Department" PAs...:heheh:

 

Just my initial thoughts...

 

Contrarian

[shawnmclane]

Medicaid has been kicking this around for about 5 years. I'm surprised they actually are moving forward with it.

[jmj11]

Medicaid has been kicking this around for about 5 years. I'm surprised they actually are moving forward with it.

 

I heard on KPLU this morning that it was going to become reality in about 5 weeks. Next thing they will stop paying for Maxalt . . . oh, they don't anyway (inside pun).

[EMEDPA]

Other conditions not covered include hypoglycemic coma and sepsis...not kidding...

the washington branch of the american college of em physicians filed suit today in state court to block the implementation of this law.

[medic25]

I mean, I see the logic, but trying to decide if chest pain is nonemergent verses emergent will be difficult on paper.

 

Walgreens will now be selling a home chest pain kit, right next to the pregnancy tests. You pee on a stick, it checks a troponin and a d-dimer, and if either one comes up positive you go to the ED confident that your visit will be paid for.

[shawnmclane]

I heard on WPLU this morning that it was going to become reality in about 5 weeks. Next thing they will stop paying for Maxalt . . . oh, they don't anyway (inside pun).

 

I worked hard on keeping Maxalt on formulary. Looks like there is a lawsuit seeking an injunction preventing implementation:

 

http://seattletimes.nwsource.com/html/health/2016370460_emergencylimits01m.html

[sbellin]

The planned implementation of this was announced several months ago so in a sense is not new news. We don’t have Fast Track or local urgent care facilities. I see the potential of those with an acute serious health problem that could be managed in the ER without admission delaying the ER visit for fear of having to put the bill until they truly have an emergent problem that requires more intensive ER and inpatient care; this will potentially drive up health care cost as opposed to reduce them. On the flip side are those that don’t care what is costs they’ll go to the ER and the expense won’t be covered by Medicaid; the hospital will end up eating the bill and eventually go under leaving a gap in the health care system and further reducing access to care of the underserved.

[EMEDPA]

. On the flip side are those that don’t care what is costs they’ll go to the ER and the expense won’t be covered by Medicaid; the hospital will end up eating the bill and eventually go under leaving a gap in the health care system and further reducing access to care of the underserved.

I see this as the more likely scenario although I think some honest folks(and particularly older folks) may hesitate to come in as you mentioned.

I did see an elderly lady with cp, very legitimate, the other day who worried that her visit would not be covered because of this.

[medic25]

I see this as the more likely scenario although I think some honest folks(and particularly older folks) may hesitate to come in as you mentioned.

I did see an elderly lady with cp, very legitimate, the other day who worried that her visit would not be covered because of this.

 

This used to be a very real problem for us when I worked as a flycar medic in a rural county. Medicare would not pay for ALS unless it was part of the transporting ambulance (all volunteer BLS services), and we used to have elderly patients refuse ALS care (even if quite sick) because they didn't want to get stuck with the big bill.

[CAdamsPAC]

One must ask (facetiously) how did it come to this and what could/should have been done to avoid reaching this point???

[EMEDPA]

Several issues...a lot of folks on medicaid actually are sicker and require more involved care. poor folks smoke more are more likely to have dm, htn, etc

the other issue is some folks with medicaid just abuse the system. many of these are essentially young healthy adults who qualify based on income. they come to the er weekly for issues like hangnails, runny nose, preganancy test, acne, chapped lips, etc issues which could be resolved with common sense or a few bucks(certainly less than the cost of a pack of smokes) at the local pharmacy.

I think everyone has a right to health care but we need to be reasonable about when and where that care is delivered. emergent cold sore tx is certainly not appropriate at a cost of 500 dollars when a pcp could deal with this for less than 50.

[CAdamsPAC]

Who says a cold sore even needs to be treated? Massive amounts of money is spent and untold resources are squandered under the guise of "health care" across this nation. I passed a billboard here in CT stating that "minor bumps and bruises to major illness" can be seen in the Child********Medical Center Emergency Room. Since when should minor bumps and bruises ever be seen in an ER, let alone be encouraged to be seen?I tell many of my patients that a good grandmother could take care of much of what I see in clinic and the ED.Some how, some way "the system "has to change. I have long advocated that "Fast Track" / Urgent Care not even be in the ED area to delink the treatment of minor/rountine complaints from the true ED patient. Folks with smokes in their pocket, reeking of ETOH ,carrying a I-Phone wearing the latest flashy sneakers, telling me they can't pay for their or their child's Amoxicillin.............well you can guess what it does!

[EMEDPA]

One issue about limiting visits to only true emergencies is that only 5% of er visits are true emergencies(need to be seen within 1 hr) according to acep. the vast majority of ed visits are urgent(need to be seen within 24 hrs) or ambulatory complaints(need to be seen within 1 week to 1 month).

if we did away with seeing all but true emergencies the vast majority of the er's in the country could be staffed with 1 or at most 2 providers and see no more than 10,000 pts/yr. I have no problem with seeing lacs, abscesses, etc in the er.

what bugs me is "runny nose x 15 min", preg test requests, etc that should be handled in a pcp's office if at all.

[Contrarian]

Yeah... those ARE problems...

 

Thing is... this new law could mean that the "runny nose" is actually CSF and a basiler Fx... and the preg test is needed to r/o a etopic...

 

If you don't do a full eval and these things exist... you are SCREWED...!!!

 

If you do a full eval and effectively rule these out... great, your license is secure... but your facility is SCREWED, cause they won't be paid for your prudent eval.

[Acebecker]

EMED -

 

It's almost as if the providers in the ED need to be given the ability to exercise clinical judgement and tell people with non-emergent issues that they can be discharged without any testing and that they should follow up with their PCP. Of course this opens up a potential for a lot of MP lawsuits as Contrarian pointed out. The situation is pretty out of control and I'm afraid that the US medical system is going to have to fail altogether before it actually gets fixed the way that it needs to be.

 

Andrew

[CAdamsPAC]

One issue about limiting visits to only true emergencies is that only 5% of er visits are true emergencies(need to be seen within 1 hr) according to acep. the vast majority of ed visits are urgent(need to be seen within 24 hrs) or ambulatory complaints(need to be seen within 1 week to 1 month).

if we did away with seeing all but true emergencies the vast majority of the er's in the country could be staffed with 1 or at most 2 providers and see no more than 10,000 pts/yr. I have no problem with seeing lacs, abscesses, etc in the er.

what bugs me is "runny nose x 15 min", preg test requests, etc that should be handled in a pcp's office if at all.

 

 

How about accepting the fact that 90%+ "Emergency Room " partients AREN'T and take the funding and resources that are being dumped across the nation into expanding EDs ...............pregnant pause.........and build and operate Ambulatory Care Centers! Launch an aggressive public information campaign to direct patients/pseudo emergencies AWAY from the EDs????Build in rewards to hospitals to do this , punish those ED that can't or won't take demonstrable actions to make Ambulatory Care Clinics available for non-emergent patients. Maybe even make it bebeficial for Primary Care practices that remain open in off hours. The truth is the current Emergency Departments are grossly misused and misunderstood by the public and mismanaged those who operate them when it comes to this issue.

[kevino]

I apologize beforehand if this post comes off somewhat scatter brained..

 

CAdamsPAC, you have lots of good ideas. By no means am I attacking your ideas, just responding to them with problems I have seen while working in various EDs for the last 3+ years. Last November I started working for a hospital system in the NW. In 2005 they opened a free standing ED, or as you called it, Ambulatory Care Center (ACC). This past winter and spring they opened two more. Two of the three have done very well recieving patients and staying busy. In fact one is serving as the root for a brand new hospital. With that being said, I think these care models can be very successful when placed in the correct regional area. Anyway, if someone can take this model of care and make it work without charing the ED rate then it could be very useful. Currently we see the "national average" of 95% non true emergencies. But we treat them like true emergencies so to speak and get them in and out quickly because we have rescources available on site (xray, ct, mri, us and lab). Additionally, all of these ED's have PCP offices in the same building. Therefore, patients can be referred to the nearby PCP's if they don't already have a PCP or someone to follow up with. Essentially these could act like a badass urgent care that actually gets **** and then refer patients back into the system to keep the patient revenue flowing.

 

As far as punish those EDs/hospitals that don't follow along with the idea, there is really no need for that because the loss of $$$ will be persuasive enough. When one of the aforementioned ACC ED's was opened a rival/neighboring hospital launched a giant smear campaign via mail/radio/tv etc. Guess what, this ED is one of the busiest of the six in the hospital system.

 

Another interesting idea, this list that the WA DSHS won't pay for is for ER visits - is it only limited to EDs?? So if one of these fictious facitlies opened up, and bill as an urgent care, that would force the state to pay for these visits correct?

 

In regards to the pt education/missue...In one area I worked we were flooded with non-emergent visits because people had no health insurance/no access to care and therefore could be seen at an ED thanks to EMTALA...in another area I work with people have such nice private insurance that they don't care getting billed for ED visits since it'll all be covered. Stark contrasts to each other but the end result is the same (kind of). How does that get solved?

 

Sorry for the ramble!

[CAdamsPAC]

I apologize beforehand if this post comes off somewhat scatter brained..

 

CAdamsPAC, you have lots of good ideas. By no means am I attacking your ideas, just responding to them with problems I have seen while working in various EDs for the last 3+ years. Last November I started working for a hospital system in the NW. In 2005 they opened a free standing ED, or as you called it, Ambulatory Care Center (ACC). This past winter and spring they opened two more. Two of the three have done very well recieving patients and staying busy. In fact one is serving as the root for a brand new hospital. With that being said, I think these care models can be very successful when placed in the correct regional area. Anyway, if someone can take this model of care and make it work without charing the ED rate then it could be very useful. Currently we see the "national average" of 95% non true emergencies. But we treat them like true emergencies so to speak and get them in and out quickly because we have rescources available on site (xray, ct, mri, us and lab). Additionally, all of these ED's have PCP offices in the same building. Therefore, patients can be referred to the nearby PCP's if they don't already have a PCP or someone to follow up with. Essentially these could act like a badass urgent care that actually gets **** and then refer patients back into the system to keep the patient revenue flowing.

 

As far as punish those EDs/hospitals that don't follow along with the idea, there is really no need for that because the loss of $$$ will be persuasive enough. When one of the aforementioned ACC ED's was opened a rival/neighboring hospital launched a giant smear campaign via mail/radio/tv etc. Guess what, this ED is one of the busiest of the six in the hospital system.

 

Another interesting idea, this list that the WA DSHS won't pay for is for ER visits - is it only limited to EDs?? So if one of these fictious facitlies opened up, and bill as an urgent care, that would force the state to pay for these visits correct?

 

In regards to the pt education/missue...In one area I worked we were flooded with non-emergent visits because people had no health insurance/no access to care and therefore could be seen at an ED thanks to EMTALA...in another area I work with people have such nice private insurance that they don't care getting billed for ED visits since it'll all be covered. Stark contrasts to each other but the end result is the same (kind of). How does that get solved?

 

Sorry for the ramble!

 

Well......The EDs aren't getting reimbursed for the non-emergent cases at the "ER Rate" anyways, so an Ambulatory Care Center will be paid at the "clinic/office visit rate" anyway. I am not suggesting "fictious" clinics be created. I say full service clinics open from 6AM to 2AM 7 days a week, can meet the needs of non-emergent patients. ( This might even mean more jobs for PAs)There has to be "skin in the game" for everyone(sorry to use this line, but I took some Compazine first) meaning those on public assistance and those insured WILL pay or be docked some how for not using the appropriate facility! The politicians and hospital administrators along with the clinicians MUST be commited to making the new system succeed. Yeah I know, the sphincters with LLB ,JD degrees will need to be reigned in too!!!The country needs to be educated and weaned off of the neurotic need to run to the ED or even the clinic for runny noses, poison ivy and bee stings like complaints!

The truth of the matter is ER Docs make a sh**load of cash from the current system and hospitals have a conduit for admi$$ions along with PCPs having a portal to dump PIA patients or escape having to deal with the appropriate outpatient/preadmission work up. The current system is failing and needs to be changed and the public needs to be informed that THEY and their unrealistic and at times selfish demands for medical paternalism will collapse the system around US! I'm rambling but that's what Old Guys do! Only 1 more PANRE before pulling the plug and getting a seat in the spectator section of health care :-) :-)