More than 18,000 emergency patients sick enough to need hospitalization would have been denied coverage of emergency care had they been Medicaid patients living in Washington State. However, since these patients live in Oregon, they were examined in the emergency department and then hospitalized.

An additional 12 percent of patients who needed emergency department services would have been denied emergency care in Washington State, and 33 percent would have needed primary care within 12 hours.

“The Washington State Medicaid plan is flawed because it assumes that physicians know the final diagnosis when a patient walks in the door,” said Robert A. Lowe, MD, MPH, professor in the Department of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University. ”But many patients come in with minor symptoms that turn out to be serious medical conditions.”

Dr. Lowe analyzed over 2.7 million emergency visits in Oregon from 2001 to 2005.  He applied the same research tool that Washington State used to develop a list of non-urgent diagnoses.

“Washington State’s proposed approach is not consistent with what research has taught us about emergency department use,” said Lowe. “This research tool was never designed to be used for triage or as a mechanism to determine whether emergency use is appropriate for required reimbursement by a health plan. This attempt to  would put patients at substantial risk.”

The Washington State plan also is in violation of the federal “prudent layperson standard,” according to the American College of Emergency Physicians (ACEP). This standard was codified into the national health care reform law, the Affordable Care Act, in 2010 and was included in the Medicare Balanced Budget Act of 1997.

Other states, including California, Iowa, Florida, Illinois, New Hampshire and Tennessee have been seeking to cut back on Medicaid because of the financial crisis — but at a time when more people are needing Medicaid because they have lost their jobs and health insurance.

“No patient should ever be in the position of having to diagnose himself,” said Dr. David Seaberg, president of ACEP.  “Physicians also often can’t make a diagnosis without running tests. For example, we can’t rule out a fracture without doing an X-ray: If a patient comes into an emergency department with what might be a broken bone, but it turns out they had a severe sprain, then the health plan still should cover the visit.”

The state Medicaid office in Washington State has developed a list of more than 500 diagnoses, without medical input from physicians in the state, it will not pay for because it deems them “nonurgent” for Medicaid emergency patients.  These include genital burns, acute bronchitis, and every kind of sprain, which can only be diagnosed after an X-ray has ruled out a broken bone.

In addition to Medicaid patients, this ruling will affect thousands of Medicare patients who are also Medicaid beneficiaries in the state. This especially affects Medicaid expansion enrollees who are ages 65 and older — one in five of them need hospitalization when they come to the emergency department.

If a patient gets into a car accident, and goes to the emergency department because their leg hurts so bad they cannot walk, they must have an x-ray to make sure they have not broken their leg,” said Dr. Seaberg. “If that x-ray is negative, Medicaid will not pay for the cost of that test or their ED visit. We use tests to rule-out serious injury and there is no way for a patient with no medical training to predict the outcomes of those tests, and it is dangerous to expect them to do so.”

According to the Washington State Health Care Authority, $98 million of the Medicaid dollars are spent in the state. About 1.5 percent of that funding is spent on emergency care, according to the Washington College of Emergency Physicians. To suggest that 35 percent of visits are non-emergent does not align with the national data of 8 percent from the Centers for Disease Control and Prevention.

“Perhaps one of the most concerning things about the plan is that it seeks to control spending — and deal with the lack of available alternative care settings — at the expense of the patient,” said Renee Hsia, MD, MSc, of the University of California (San Francisco), who has conducted numerous studies on evaluating emergency department use in several states and nationwide.

“The emergency department is the first resort for patients, and also the last resort. If there are no alternatives for people to get medical care, how can you deny them coverage for a urinary tract infection or for a complication from Alzheimer’s?”

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education.

Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

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