State Medicaid Programs Increasingly Seek ED Limits

WASHINGTON – As states wrestle with tight budgets and growing Medicaid rolls, more are exploring restricting payment for emergency department visits.

California, Illinois, Iowa, New Hampshire, Tennessee, Washington, and other states have been seeking to cut back on Medicaid payments for ED care.

Iowa has instituted a tiered payment plan for nonemergency care, with reductions of 25%-100% in the prevailing rate, said Dr. Sandra Schneider, immediate past president of the American College of Emergency Physicians (ACEP) and a member of the board of directors of the New York State Chapter of ACEP. Texas has also cut rates based on the acuity of the visit. New Hampshire has proposed a four-visit yearly limit, and Illinois and Kentucky have also discussed limiting visits, Dr. Schneider said at a conference sponsored by the American College of Emergency Physicians.

In Washington state, ACEP and the state medical society and hospital association were able to negotiate a postponement of a restrictive policy that was due to go into effect last October. Efforts to prevent similar policies from going into effect in Tennessee have been marginally successful so far.

Speakers at the ACEP Leadership and Advocacy Conference outlined the success in Washington and the struggle in Tennessee, describing both as cautionary tales in the continuing tough budget environment.

"We are under attack," said Dr. Schneider, noting that proposed restrictions on EDs are disproportionate given that emergency care accounts for only 2% of all health care costs and emergency doctors comprise only 4% of the nation’s physicians.

In the early summer of 2011, the Washington state legislature passed a law to cap nonemergency visits to the ED, and directed the state Medicaid program to formulate a list of nonemergent conditions in coordination with the state’s physicians and hospitals.

But the state’s Health Care Authority (HCA) drafted its own list and moved to put the policy into place in October. The Washington State Chapter of ACEP filed suit the day before the policy was to take effect. The Washington Chapter and national ACEP contributed about $200,000 to pay for the lawsuit, said Dr. Nathaniel R. Schlicher, who is a board member of ACEP’s Washington Chapter and a clinician at St. Joseph Medical Center in Tacoma.

In November, a judge agreed with ACEP that the policy could not be implemented and enjoined the HCA from moving ahead. A new collaborative process began but quickly devolved; the state changed its position from allowing three nonemergent ED visits a year to allowing none, said Dr. Schlicher. The "do not cover" list included 515 diagnoses, with absolutely no exceptions, he said.

The Washington Chapter of ACEP, the Washington State Medical Association, and the Washington State Hospital Association combined forces to defeat the policy, but continued negotiations with the HCA, said Dr. Schlicher. The groups launched a media campaign to discredit the Medicaid policy, and members conducted grand rounds at hospitals to explain the policy’s potential impact.

Their efforts focused, however, on getting the legislature to accept an alternative plan that would produce the savings needed to meet the state’s budget without endangering patients.

The groups enlisted the help of Rep. Eileen Cody, a member of the state House from West Seattle who also was the chair of the health care committee, to broker talks with the House and Senate. The House included the alternative policy in its budget, but when the Senate failed to pass it, Gov. Christine Gregoire (D) called a special session of the legislature in March. The budget finally passed by the Senate did not include the alternative plan.

Then, in April, Gov. Gregoire suspended the zero tolerance policy and added the alternative proposal as a proviso to the state budget. Under that proposal, hospitals will commit to participating in the Emergency Department Information Exchange (EDIE), which will help them track and manage frequent ED users. With the EDIE, physicians can view previous visits and discharge plans. Much of the focus is on managing those who are drug seekers, and systems will be set up to help these patients access primary care providers and to help physicians follow ACEP guidance on prescribing and monitoring narcotics.

Physicians also will be urged to participate in an online prescription database to track patients’ use of controlled substances. The goal is to have 90% of EDs participating by the end of this year.

Utilization monitoring reports – tracking rates of unnecessary visits, rates of visits by frequent users, and rates of opioid prescriptions – will be reported to the HCA. In turn, physicians will get feedback reports to help them improve their practices.

All hospitals with at least 75% of visits covered by Medicaid must participate or the state will revert to its zero visit policy.

Tennessee has also attempted to limit ED visits by Medicaid patients, said Dr. Sanford H. Herman, immediate past president of the Tennessee Chapter of ACEP and an emergency physician in Nashville. The state’s traditional Medicaid program was replaced in 1994 by a network of 12 managed care organizations called TennCare. TennCare was supposed to be more efficient and less costly, but it was on its way to consuming half of the state’s budget by the late 2000s, Dr. Herman said.

In 2005, then-Governor Phil Bredesen (D) began slashing TennCare’s funding. In 2010, about $525 million was cut and some 200,000-300,000 enrollees were dropped, said Dr. Herman.

The state proposed limiting ED visits to eight per year and eliminating pay for certain nonemergent conditions. Any other proposal – such as changing benefits or increasing cost-sharing – would have required approval from the U.S. Centers for Medicare and Medicaid Services.

The Tennessee Chapter began meeting with state officials to head off the policy. In April 2011, when the 2012 budget was being formulated, the Chapter learned that visits for nonemergent services would be reimbursed at the rate of a level 1 office visit, or $17. The list of such services was more than 200 pages long, Dr. Herman said.

Lobbying efforts resulted in the $17 becoming $50, at least for the next year. The Tennessee Chapter is working with the current governor and TennCare to come up with a larger solution to help stop the bleeding from the state’s coffers, he said.

Meanwhile, representatives of the Tennessee Chapter go to the State Capitol building every Tuesday and Wednesday to continue the campaign, Dr. Herman said.

Dr. Herman, Dr. Schneider, and Dr. Schlicher urged emergency physicians to get involved in the state Medicaid battles. "Keep your ears and eyes open," said Dr. Schneider, who also recommended that doctors alert the national ACEP organization when a potentially onerous policy is being discussed or proposed "because these people have your back," she said.

WASHINGTON – As states wrestle with tight budgets and growing Medicaid rolls, more are exploring restricting payment for emergency department visits.

California, Illinois, Iowa, New Hampshire, Tennessee, Washington, and other states have been seeking to cut back on Medicaid payments for ED care.

Iowa has instituted a tiered payment plan for nonemergency care, with reductions of 25%-100% in the prevailing rate, said Dr. Sandra Schneider, immediate past president of the American College of Emergency Physicians (ACEP) and a member of the board of directors of the New York State Chapter of ACEP. Texas has also cut rates based on the acuity of the visit. New Hampshire has proposed a four-visit yearly limit, and Illinois and Kentucky have also discussed limiting visits, Dr. Schneider said at a conference sponsored by the American College of Emergency Physicians.

In Washington state, ACEP and the state medical society and hospital association were able to negotiate a postponement of a restrictive policy that was due to go into effect last October. Efforts to prevent similar policies from going into effect in Tennessee have been marginally successful so far.

Speakers at the ACEP Leadership and Advocacy Conference outlined the success in Washington and the struggle in Tennessee, describing both as cautionary tales in the continuing tough budget environment.

"We are under attack," said Dr. Schneider, noting that proposed restrictions on EDs are disproportionate given that emergency care accounts for only 2% of all health care costs and emergency doctors comprise only 4% of the nation’s physicians.

In the early summer of 2011, the Washington state legislature passed a law to cap nonemergency visits to the ED, and directed the state Medicaid program to formulate a list of nonemergent conditions in coordination with the state’s physicians and hospitals.

But the state’s Health Care Authority (HCA) drafted its own list and moved to put the policy into place in October. The Washington State Chapter of ACEP filed suit the day before the policy was to take effect. The Washington Chapter and national ACEP contributed about $200,000 to pay for the lawsuit, said Dr. Nathaniel R. Schlicher, who is a board member of ACEP’s Washington Chapter and a clinician at St. Joseph Medical Center in Tacoma.

In November, a judge agreed with ACEP that the policy could not be implemented and enjoined the HCA from moving ahead. A new collaborative process began but quickly devolved; the state changed its position from allowing three nonemergent ED visits a year to allowing none, said Dr. Schlicher. The "do not cover" list included 515 diagnoses, with absolutely no exceptions, he said.

The Washington Chapter of ACEP, the Washington State Medical Association, and the Washington State Hospital Association combined forces to defeat the policy, but continued negotiations with the HCA, said Dr. Schlicher. The groups launched a media campaign to discredit the Medicaid policy, and members conducted grand rounds at hospitals to explain the policy’s potential impact.

Their efforts focused, however, on getting the legislature to accept an alternative plan that would produce the savings needed to meet the state’s budget without endangering patients.

The groups enlisted the help of Rep. Eileen Cody, a member of the state House from West Seattle who also was the chair of the health care committee, to broker talks with the House and Senate. The House included the alternative policy in its budget, but when the Senate failed to pass it, Gov. Christine Gregoire (D) called a special session of the legislature in March. The budget finally passed by the Senate did not include the alternative plan.

Then, in April, Gov. Gregoire suspended the zero tolerance policy and added the alternative proposal as a proviso to the state budget. Under that proposal, hospitals will commit to participating in the Emergency Department Information Exchange (EDIE), which will help them track and manage frequent ED users. With the EDIE, physicians can view previous visits and discharge plans. Much of the focus is on managing those who are drug seekers, and systems will be set up to help these patients access primary care providers and to help physicians follow ACEP guidance on prescribing and monitoring narcotics.

Physicians also will be urged to participate in an online prescription database to track patients’ use of controlled substances. The goal is to have 90% of EDs participating by the end of this year.

Utilization monitoring reports – tracking rates of unnecessary visits, rates of visits by frequent users, and rates of opioid prescriptions – will be reported to the HCA. In turn, physicians will get feedback reports to help them improve their practices.

All hospitals with at least 75% of visits covered by Medicaid must participate or the state will revert to its zero visit policy.

Tennessee has also attempted to limit ED visits by Medicaid patients, said Dr. Sanford H. Herman, immediate past president of the Tennessee Chapter of ACEP and an emergency physician in Nashville. The state’s traditional Medicaid program was replaced in 1994 by a network of 12 managed care organizations called TennCare. TennCare was supposed to be more efficient and less costly, but it was on its way to consuming half of the state’s budget by the late 2000s, Dr. Herman said.

In 2005, then-Governor Phil Bredesen (D) began slashing TennCare’s funding. In 2010, about $525 million was cut and some 200,000-300,000 enrollees were dropped, said Dr. Herman.

The state proposed limiting ED visits to eight per year and eliminating pay for certain nonemergent conditions. Any other proposal – such as changing benefits or increasing cost-sharing – would have required approval from the U.S. Centers for Medicare and Medicaid Services.

The Tennessee Chapter began meeting with state officials to head off the policy. In April 2011, when the 2012 budget was being formulated, the Chapter learned that visits for nonemergent services would be reimbursed at the rate of a level 1 office visit, or $17. The list of such services was more than 200 pages long, Dr. Herman said.

Lobbying efforts resulted in the $17 becoming $50, at least for the next year. The Tennessee Chapter is working with the current governor and TennCare to come up with a larger solution to help stop the bleeding from the state’s coffers, he said.

Meanwhile, representatives of the Tennessee Chapter go to the State Capitol building every Tuesday and Wednesday to continue the campaign, Dr. Herman said.

Dr. Herman, Dr. Schneider, and Dr. Schlicher urged emergency physicians to get involved in the state Medicaid battles. "Keep your ears and eyes open," said Dr. Schneider, who also recommended that doctors alert the national ACEP organization when a potentially onerous policy is being discussed or proposed "because these people have your back," she said.

WASHINGTON – As states wrestle with tight budgets and growing Medicaid rolls, more are exploring restricting payment for emergency department visits.

California, Illinois, Iowa, New Hampshire, Tennessee, Washington, and other states have been seeking to cut back on Medicaid payments for ED care.

Iowa has instituted a tiered payment plan for nonemergency care, with reductions of 25%-100% in the prevailing rate, said Dr. Sandra Schneider, immediate past president of the American College of Emergency Physicians (ACEP) and a member of the board of directors of the New York State Chapter of ACEP. Texas has also cut rates based on the acuity of the visit. New Hampshire has proposed a four-visit yearly limit, and Illinois and Kentucky have also discussed limiting visits, Dr. Schneider said at a conference sponsored by the American College of Emergency Physicians.

In Washington state, ACEP and the state medical society and hospital association were able to negotiate a postponement of a restrictive policy that was due to go into effect last October. Efforts to prevent similar policies from going into effect in Tennessee have been marginally successful so far.

Speakers at the ACEP Leadership and Advocacy Conference outlined the success in Washington and the struggle in Tennessee, describing both as cautionary tales in the continuing tough budget environment.

"We are under attack," said Dr. Schneider, noting that proposed restrictions on EDs are disproportionate given that emergency care accounts for only 2% of all health care costs and emergency doctors comprise only 4% of the nation’s physicians.

In the early summer of 2011, the Washington state legislature passed a law to cap nonemergency visits to the ED, and directed the state Medicaid program to formulate a list of nonemergent conditions in coordination with the state’s physicians and hospitals.

But the state’s Health Care Authority (HCA) drafted its own list and moved to put the policy into place in October. The Washington State Chapter of ACEP filed suit the day before the policy was to take effect. The Washington Chapter and national ACEP contributed about $200,000 to pay for the lawsuit, said Dr. Nathaniel R. Schlicher, who is a board member of ACEP’s Washington Chapter and a clinician at St. Joseph Medical Center in Tacoma.

In November, a judge agreed with ACEP that the policy could not be implemented and enjoined the HCA from moving ahead. A new collaborative process began but quickly devolved; the state changed its position from allowing three nonemergent ED visits a year to allowing none, said Dr. Schlicher. The "do not cover" list included 515 diagnoses, with absolutely no exceptions, he said.

The Washington Chapter of ACEP, the Washington State Medical Association, and the Washington State Hospital Association combined forces to defeat the policy, but continued negotiations with the HCA, said Dr. Schlicher. The groups launched a media campaign to discredit the Medicaid policy, and members conducted grand rounds at hospitals to explain the policy’s potential impact.

Their efforts focused, however, on getting the legislature to accept an alternative plan that would produce the savings needed to meet the state’s budget without endangering patients.

The groups enlisted the help of Rep. Eileen Cody, a member of the state House from West Seattle who also was the chair of the health care committee, to broker talks with the House and Senate. The House included the alternative policy in its budget, but when the Senate failed to pass it, Gov. Christine Gregoire (D) called a special session of the legislature in March. The budget finally passed by the Senate did not include the alternative plan.

Then, in April, Gov. Gregoire suspended the zero tolerance policy and added the alternative proposal as a proviso to the state budget. Under that proposal, hospitals will commit to participating in the Emergency Department Information Exchange (EDIE), which will help them track and manage frequent ED users. With the EDIE, physicians can view previous visits and discharge plans. Much of the focus is on managing those who are drug seekers, and systems will be set up to help these patients access primary care providers and to help physicians follow ACEP guidance on prescribing and monitoring narcotics.

Physicians also will be urged to participate in an online prescription database to track patients’ use of controlled substances. The goal is to have 90% of EDs participating by the end of this year.

Utilization monitoring reports – tracking rates of unnecessary visits, rates of visits by frequent users, and rates of opioid prescriptions – will be reported to the HCA. In turn, physicians will get feedback reports to help them improve their practices.

All hospitals with at least 75% of visits covered by Medicaid must participate or the state will revert to its zero visit policy.

Tennessee has also attempted to limit ED visits by Medicaid patients, said Dr. Sanford H. Herman, immediate past president of the Tennessee Chapter of ACEP and an emergency physician in Nashville. The state’s traditional Medicaid program was replaced in 1994 by a network of 12 managed care organizations called TennCare. TennCare was supposed to be more efficient and less costly, but it was on its way to consuming half of the state’s budget by the late 2000s, Dr. Herman said.

In 2005, then-Governor Phil Bredesen (D) began slashing TennCare’s funding. In 2010, about $525 million was cut and some 200,000-300,000 enrollees were dropped, said Dr. Herman.

The state proposed limiting ED visits to eight per year and eliminating pay for certain nonemergent conditions. Any other proposal – such as changing benefits or increasing cost-sharing – would have required approval from the U.S. Centers for Medicare and Medicaid Services.

The Tennessee Chapter began meeting with state officials to head off the policy. In April 2011, when the 2012 budget was being formulated, the Chapter learned that visits for nonemergent services would be reimbursed at the rate of a level 1 office visit, or $17. The list of such services was more than 200 pages long, Dr. Herman said.

Lobbying efforts resulted in the $17 becoming $50, at least for the next year. The Tennessee Chapter is working with the current governor and TennCare to come up with a larger solution to help stop the bleeding from the state’s coffers, he said.

Meanwhile, representatives of the Tennessee Chapter go to the State Capitol building every Tuesday and Wednesday to continue the campaign, Dr. Herman said.

Dr. Herman, Dr. Schneider, and Dr. Schlicher urged emergency physicians to get involved in the state Medicaid battles. "Keep your ears and eyes open," said Dr. Schneider, who also recommended that doctors alert the national ACEP organization when a potentially onerous policy is being discussed or proposed "because these people have your back," she said.