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“Illegal” Limits on Emergency Department Use

According to an article in the Miami Herald, Florida is “illegally” limiting Medicaid patients to six emergency department visits per year. Federal officials call such arbitrary limits illegal and says that the limits would not be in a patient’s best interests. CMS intends to withhold a portion of Florida’s Medicaid funding as a result. Another article on ThinkProgress.org comments on how unfair and inappropriate the limits would be, especially since only a “sliver of the poorest Florida residents” are eligible for Medicaid. The total population in Floirda is 19.5 million. The number of Florida residents eligible for Medicaid is 3.3 million. That’s 17% of Florida residents eligible for Medicaid. Add to that another 3.1 million Florida residents who have Medicare benefits (although there is likely some overlap with patients who have both Medicare and Medicaid) and you’re looking at one third of Florida’s population that receive medical care from the government. Some fricking “sliver.”

Aside from the misinformation that reporter Sy Mukherjee is perpetuating, the story raised several additional issues with me.

First, if acts that are not in a patient’s “best interests” violate the Social Security Act, then how did Obamacare pass muster? Not enough doctors in the system: not in a patient’s best interests. Outlawing established insurance plans: not in a patient’s best interests. Byzantine registration process: not in a patient’s best interests. Inappropriate Healthcare.gov web site security: not in a patient’s best interests.

Second, I was surprised by the number of people commenting on the articles who deemed Gov. Rick Scott’s attempts to limit excessive emergency department use as:

  • intended to harm poor people
  • “DEATH PANELS,”
  • a form of fascism
  • a form of criminal Naziism
  • preventing “Medicaid patients from receiving legitimate treatment”

There were also multiple ad hominem attacks tossed at Gov. Rick Scott for taking steps to shore up the state’s budget.

Want a couple of easy ways to solve this problem? Get rid of the rationing. All it will do is incite people whose services may be rationed. Change must come from within.

First, publish the names (pictures?) of the top 50 ED users each month/each quarter/each year in the newspapers and on websites throughout the state. Announce that this list will be published in advance so patients are given fair notice. Don’t have to publish any medical data or the hospitals involved – just publish the number of visits the patient made and the costs involved in providing care for each patient. Post the lists in the waiting rooms of the hospital emergency departments. If the public is paying for the care of these individuals, the public has a right to know who is receiving the public’s money. Sunlight is the best disinfectant.
Then, require mandatory co-pays for all emergency department visits … regardless of the medical problem … regardless of the urgency. Other patients don’t get free health care just because they’re having an emergency. Why should we create a privileged class of patients who receive all their medical care at no cost? Everyone should pay something for their medical care. Non-urgent cases still pay a co-pay, receive a screening exam and then must be discharged to a federal health clinic for follow up care. Not enough federal health clinics? That’s not in a patient’s best interests. The federal government is violating the Social Security Act.
If the patient doesn’t have money for the co-pay, deduct the costs of the copay from any future forms of government assistance that the patient may obtain each month.

Controversial? Sure. Effective? Absolutely.

If you don’t agree with me, give me some better ideas on how to cut costs in the comments section.

17 comments

  1. Around here, a group of hospitals (taking the # of ER visits combined between the three) started sending letters out to patients with > 8 visits in a 12-month period. They got the # of frequent flyers down from like 575 to 370-something with letters to those who appeared to be drug-seeking by simply stating that they would not be receiving narcotics in these three ERs in the future. Of course, they probably just went elsewhere, but still.

    Six ER visits is excessive for all medical conditions if you’re doing proper follow-up.

    • So K …

      First, when you going to start blogging again? I have a chronic snark deficiency in your absence.

      Second, one of the places that I used to work did the same thing with the letters to patients on “the List.” Initially cut down on some ED visits, but then not all the docs bought into the “you get no Dilaudid ever” program. So visits actually went up a little because the frequent flyer patients would come back to the hospitals after shift change in hopes that Dr. FeelGood was working the new shift. Then Dr. FeelGood got an ultimatum and left. Frequent flyer visits again went down a little, but so did satisfaction scores … which caused hospital to trash the whole program.

      Unintended consequences that a grade-schooler working in the ED could figure out, but admin wasn’t really interested in anyone’s opinions but their own.

  2. This is simple, and requires none of the privacy-violating provisions suggested:

    Inform patients that they will be liable to reimburse THE FEDERAL GOVERNMENT for the cost of all services delivered through the emergency department that are determined by the treating physician to be non-emergent.
    Turn the delinquent debtors over to the tender loving care and supervision of the IRS.
    The hospital still gets paid for delivering the services billed for, as they should.

    See how much fun EMTALA is when the .gov is paying the bills they handed off to everyone else nearly 30 years ago. People were sold on HopeyDopeyCare under the premise that Somedood would pay for it. Surprise, surprise, Somedood is now the patient. If you like your crap sammich, you can eat your crap sammich.

    The quickest way to reform it (ideally, by repealing it exactly like the 18th Amendment) is to force those who receive something to actually pay the costs and face the penalties, and making the federal government fund the unfunded mandate they laid off on EDs and hospitals since the mid-1980s.

    Happily the only thing this requires from the bottom of the totem pole is for the treating ED doctors to check a box at discharge.

    • I think that if patients had to reimburse the Feds for non-emergent care, they would still game the system. For example: “I’m having crushing chest pain for the past 12 hours … and by the way, while I’m here getting worked up for my emergency chest pain, what do you think is causing this rash on my arm for the past 3 months?”
      Either that or the docs would be pressured through other means to overclassify visits as emergencies so that patients wouldn’t have to pay their bills. See Press Ganey posts on this blog.

      I agree that EMTALA is ridiculous. Another example of unintended consequences and how legislation begets more legislation to fix the unintended consequences.
      As CMS ratchets down on payments, EMTALA will be exploited by hospitals. No emergency? No treatment. Want pain medications or antibiotics? Pay up front or go get the prescription somewhere else.

      The problem with forcing everyone to pay full price for medical care is that there are many people who simply can’t afford it. There needs to be a safety net. That safety net is the responsibility of the government, not of private enterprises.
      An ancillary problem is that there is no price transparency so that people who might be able to pay for their medical care have no way to comparison shop.

      • Ah, but we now have HopeyDopeyCare.
        EVERYONE can get a card now.
        (And they game the system already. The answer is to treat the emergency condition, admit or discharge, and then make them sign in and wait all over again to get seen for separate unrelated whiny little BS. Liberal use of prophylactic doses of activated charcoal, NG tubes, foley catheters, and enemas, sadly, are completely unethical, but when indicated medically, definitely cut down on repeats of such behaviors. I’ve heard.)

        Wait, you mean the government isn’t actually paying for everything??
        But…but…but…

        As the Unaffordable Care Act trickles down, it will merely accelerate ED and hospital closures (>80 in CA over ten years, when last I checked, probably over 100 by now since ’95).

        The ED is/was the last chance to get health care for more and more people. When one tries to put more and more people in less and less lifeboats, everyone dies.

        This is not only the current governmental care model, it’s the design of the entire plan.

        Listing the prices is a blatantly capitalistic move.
        If we still had anything like a free market, it would be a solution, and one I’d cheer.

        But in this environment, it will merely create the last panicked rush to the lifeboat with the lowest price, which will then be swamped, ad infinitum, until they’re all gone, or the only choice anywhere is 24-48 hour waits for basic care in the Waiting Room From Hell, and from hospitals run by the government that make the VA and the DMV seem caring , compassionate, and efficient by comparison.

        Just like the Soviet system from 1919-1989, and to only slightly lesser degrees, every other national health system ever implemented anywhere on the planet outside of a couple of oil sheikdoms with 2000 clients and 4000 oil wells.

  3. The only way to keep people from abusing a service is to make sure they have some skin in the game. Some type of co-pay is needed. It needs to be significant enough to make them stop and think…is this emergent enough that I’m willing to cough up X amount of dollars?

    If it’s free they won’t think twice. Heck, they won’t think once nor will they try to fix their health issue if they can just keep putting free band-aids on it.

  4. When administration is more interested in their patient satisfaction scores (Press Ganey and others) than in good patient care, the physicians’ hands are tied literally and metaphorically. It takes a Medical Staff Director and an ED director with gonads of steel to stand up to those who hold the purse strings.

    Most non-emergent ED visits can be resolved with minimal intervention – from my own anecdotal experience, meds off the Wal-Mart/Walgreen’s/Etc. $4 pharmacy suffice. Proper follow-up will be a problem that will only get worse as primary care is kicked repeatedly until unconscious then dead.

  5. ifeelwarmandfuzzy

    Why not establish a prescreen ER program? Rather then admit anyone determine if whatever the “injury/disease” etc requires ER attention. If not refer them to an immediate care or a primary physician. In case of a sue happy patron make sure to use words such as “recommend” and have them sign a waiver. Could work….

    • NIce thought. Some EDs are doing this. Some cannot because 1. there is no money, 2. there is not good primary care/urgent care infrastructure around (ie. rural areas), and 3. MedicAid programs across the country have spent a generation teaching people that they can go to the ED for most any little complaint with little or no cost to themselves. A habit like that is exceedingly hard to break.

      The length of time the average child has had a fever in my ED is < 10hours. (I kept my own stats for 3 months). The % whose parents gave them either motrin OR tylenol OR attempted some other manner of fever reduction was less than 30%.

      • “A habit like that is exceedingly hard to break.”

        I’ve come to a similar conclusion, and my answer (which I don’t claim is perfect) is: don’t break it. Instead, incorporate an urgent care track (staffed by mid-levels) in as many EDs as feasible (obviously you need a certain volume). Then someone (not you) provides primary care with a smile to those that need it, and you focus on the kind of things you were trained to do.

        When my ED has double mid-level coverage at busy times, my admission rate goes from 20-30% to 50-90%. It’s an extraordinary difference. I’m not saying it’s easy, because in point of fact admitting a dozen patients per shift is not easy, but it does keep you mostly caring for people who have an actual need for emergency services.

        • Yup. We tried that. And it worked fairly well. Not perfect, but it was better.

          2 months ago the federal gov’t put a hold on several million dollars coming from Medicaid that forced the entire hospital to cut back to bare bones staffing. They’ve promised us what we’re due, but pushed the payment back 12 months. Never mind that this is the first time they ever done such a thing since I came on staff and the Medical Staff Exec Board (6yrs)… and never mind that it come from our indigent care for all of last year (i.e. it is about 18cents on the dollar).

          So we cut.

          This included our fast track and the double-coverage for MDs during our busiest time (3p-11p). Now, we are back to where we were for staffing in 2005: 1 doc each 7a-7p, 7p-7a, and 1 PA from 9a-7p and 7p – 5a. Two critically ill patients can kill our throughput for 2 hours.

          It is getting ugly.

          • Once the money comes (only a couple of us are saying ‘if’), we’ll be back to business as usual.

  6. Simple. Universal healthcare via a national health service. Better and cheaper, which is why the OCED average is half what the US spends.

    • Because that’s worked so abysmally well everywhere it’s been tried.
      It’s never better, nor cheaper, but it is more universal, because like most weeds, it chokes off all competition.
      Wouldn’t it be cheaper and more ethical to simply reintroduce smallpox to the world, and cease production of tetanus vaccine?

      “The problem with socialism is that eventually, you run out of other people’s money.”

      The current role of ObamaCare is simply to utterly ruin the former system we had, until single-payer national health is the only thing left to “fix” all the problems ObamaCare created.
      Which is here to fix all the problems EMTALA created.
      Which was instituted to fix all the problems Medicare and Medicaid created.

      Perhaps you’ll notice a pattern here, similar to the introduction of opium for pain, which was addictive, but cured by getting people off opium and onto laudanum, which was addictive, which was cured by getting people off of laudanum and onto heroin, which was addictive, which was cured by getting people off of heroin and onto methadone, which was addictive, which was…

      If you’d start from the premise that medical care is a commodity like automobiles, and not a birthright, we could have a decent discussion on the point below which the government (which means all of us) should provide a stripped down and highly subsidized basic version, and to whom, and look at for how much of that the rest of us were willing to pay.

      Otherwise, there’s no philosophic reason not to view food and drink as a human right, outlaw all restaurants and markets, and let the government decide how much food and of what type we would all be handed, week to week, regardless of what we want or can afford.

      • I want you to run for Congress and I want to be your campaign manager.

        • Thanks.
          It’s a novel thought, being that we’re probably several states distant, but unfortunately, I’m not eligible to run for political office.

          My parents were married to each other.

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