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Legislative Fixes

Washington State drops its plans to limit Medicaid patients to three emergency department visits per year. Instead, Washington plans to institute a policy of refusing to pay for any emergency department visits by Medicaid patients that are deemed “unnecessary.”

What effect will this policy have?

Medicaid patients can’t/won’t be charged for the “unnecessary” visits.
Washington state will no longer pay for the “unnecessary” visits.
Therefore, hospitals and medical providers take a financial hit if the state makes a retrospective determination that a visit is “unnecessary.”

In order to make the determination whether a visit is “necessary” or not, Washington State officials must rely upon what is written in the patient’s chart to determine a patient’s complaints, diagnosis, and workups. Who controls what complaints are emphasized on the charts and how the complaints are worked up? The same providers that will be financially liable if the visits are deemed “unnecessary.”

If this policy survives the legal challenges that are being mounted against it, look for a sharp increase in the number of patients diagnoses that Washington State does not deem “unnecessary.”

The funny thing is that when you pay for a result, you often get the result. Remember when Medicare started docking hospitals that had central line related bloodstream infections? When hospitals don’t get paid for patients with central line related bloodstream infections, the incidence of such infections plummets. But the incidence of bloodstream infections in general goes up. It’s all in how you define the issue.
With emergency patients, the demographics won’t change. The patient complaints won’t change. The diagnoses will change a lot – especially if patients know that they might be triaged out of the emergency department without receiving care and sent to a medical clinic if they have certain “unnecessary” complaints. If I was running a hospital, I would even put a sign up in the waiting room stating which complaints/conditions that Washington State would pay for and telling patients that after they receive their federally mandated triage exam, they may be sent to a clinic for their care if they do not have one of those conditions.

Because reimbursable diagnoses are usually paid at a higher level, I think it’s a safe bet that Washington State will end up paying out more money for emergency department visits by Medicaid patients. Your baby needs to be seen for a cough? Coughing is an “unnecessary” complaint. But, that cough could represent RSV pneumonitis or pneumonia. Those aren’t “unnecessary” diagnoses. Instead of giving you some cough medication and discharging you, we should probably do some blood work, a chest x-ray, and get a nebulizer treatment going just to make sure that there’s no pneumonia or RSV present.

When legislators try to fix a system that they know nothing about, they often just make the system worse.
And then they need to create more regulations to try to fix the problems they created with the initial regulations.

We’re from the government. We’re here to help.


  1. I realize that patients making unnecessary trips to an emergency room are a huge problem for hospitals. There use to be charity hospitals for those in need of medical care that could not afford it, now that those are gone, if a person is sick, and the doctor won’t see them without payment in full, those patients turn to emergency rooms because that is the only way they can get help. Instead of having a one hundred or so dollar bill they can’t pay, they have a 500.00 or so bill they can’t pay. I use to have great insurance, but because of cut backs, I am now considered on call. One day of doctor visits cost me two weeks of my pay. I can’t survive like that, but have no choice because decent paying jobs are limited. Even Walmart is cutting it’s workers benefits and making them all on call to avoid health care benefits.

  2. Volunteer Nurse Advocate

    Many docs send their patients to the ER because they are not available. In this case the ER doc serves as the physicians’s agent, not the patients. The patient goes to the ER. The ER runs a bunch of tests, does an exam, finds nothing yet tells the patient to go back to their physician who couldn’t see them in the first. The ER gets to bill Medicaid, Medicare, private insurance etc. The patient then gets bounced back to their doc because after all they want a piece of the pie that they missed the first time around not to mention the fact that the ER gets to protect their liability. The patient goes back to their doc in a few days and they do more tests and bill Medicaid, Medicare, private insurance etc for another visit all the while protecting their liability. There is something wrong with this picture. Legislators, clinic administrators, doctors and patients all need to be educated about the proper use of the Emergency Room.

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