As state moves to limit Medicaid funding for ER visits, group wants to educate patients on health care options

YAKIMA, Wash. — A group of Yakima Valley medical providers wants to help low-income patients avoid new financial burdens when they turn too often to the emergency room complaining of runny noses and other non-emergencies.

Led by Yakima Valley Memorial Hospital, the group says it wants to protect financially and medically vulnerable people from incurring certain ER bills for non-emergency visits that will no longer be covered by Medicaid, the health program for the poor and disabled.

In a controversial move directed by the cash-strapped 2010 Legislature, the state Medicaid program on Oct. 1 began paying for only three non-emergency visits to the ER per year.

To keep patients from going over the limit, medical providers will counsel them on how to find a primary care practice or clinic that would become their "home" for medical needs that are not life-threatening.

"Many folks are used to going to the ER because they think it's the best care, but this is an opportunity to educate them on accessing their medical home," said Annette Rodriguez, outreach coordinator with Yakima Neighborhood Health Services.

The new law potentially affects as many as 85,000 people in Yakima County, where 25,442 adults and 59,421 children are Medicaid clients. Not all of them, of course, use the ER for routine medical care.

Statewide, the problem among Medicaid clients appears small. The state Health Care Authority, which administers Medicaid, estimates that 11,000 people used the ER for more than three non-emergency visits in the 2010 fiscal year. Medicaid has 1.2 million clients statewide, making the frequent users only a small percentage of the Medicaid population.

Still, the state says the problem has been growing, and at $35 million a year the potential savings by cutting back on these visits is substantial. Emergency room care is notoriously expensive because the departments are staffed 24 hours every day of the week.

The state's new law will also save the federal government about $37 million because Medicaid is jointly funded by the state and federal governments.

While an ER visit can exceed $1,000, seeing a primary care doctor may cost about $150.

Sandy Dahl, vice president and chief clinical officer at Memorial, said the local medical system has to be more "user friendly" if Medicaid clients are going to start thinking of alternatives to the ER.

"We feel like there is access to primary care. However, it's not the first place the patient often goes," Dahl said.

While recruitment efforts have brought more primary care doctors to Yakima, Memorial and other providers are looking to expand after-hours appointments at clinics and practices to get patients to the right place when they feel they need to see someone quickly.

The group includes the Yakima Valley Farm Workers Clinic, Yakima Neighborhood Health Services, Community Health of Central Washington, Aging and Long Term Care, Comprehensive Mental Health of Central Washington, Yakima County Department of Human Services, Central Washington Health Care Partners, ESD 105 and Memorial Physicians.

Yakima Regional Medical and Cardiac Center says it has been doing patient education about the need for a primary doctor on an ongoing basis. The hospital's chief operating officer, Cindi Butcher, said the new policy won't change how Medicaid clients are treated in the ER.

"We don't know who payer is when they come in, to comply with federal guidelines. Until the point we rule out it's an emergency, we don't ask many questions," Butcher said.

But she said the new law poses problems. For example, Medicaid says anyone arriving at the ER in an ambulance will be treated as an emergency, which could provide a loophole.

"Does that mean people who call 911 with a sore throat will get the visit covered? It's a challenging time."

'Prudent layperson' standard

The limit on ER visits, a policy only a few other states have adopted or considered, is pioneering in that it aims to change behavior that will lower health-care costs.

But it's also highly controversial, because federal law prohibits hospitals from turning away anyone seeking treatment, regardless of their ability to pay.

What's more, some of the medical conditions that won't be reimbursed after three visits -- including "non-cardiac generalized chest pain" -- could be actual emergencies, many doctors and hospitals say.

The new law is being challenged in court by the American College of Emergency Physicians, the Washington State Medical Society and the Washington State Hospital Association.

These groups argue the law violates well-established standards of care designed to protect vulnerable patients facing life-threatening medical problems.

One of those standards, the so-called "prudent layperson" rule, was established many years ago to determine the need to visit the ER. It defines an emergency as a condition that a prudent lay person -- with an average knowledge of health and medicine -- expects may be life-threatening.

The rule was deemed necessary because patients were arriving at ERs complaining of chest pain and getting a full work-up as a result. If there was no medical determination of a cardiac event, insurers were refusing to pay.

"The feds stepped in and said a prudent person would reasonably think this chest pain could be life-threatening," said Dr. Chris Schmelzer, an emergency room physician at Memorial.

Now the new law, Schmelzer argues, creates a double standard: one for the privately insured who will still get coverage even if they aren't diagnosed with a heart attack, and one for Medicaid clients who may not.

"It creates a troubling double standard for some of the most vulnerable people in our society," Schmelzer said.

But Dr. Jeffrey Thompson, chief medical officer for the state Medicaid program, said the new law doesn't change any standards, which he said are intended to prevent hospitals from "dumping" sick patients on other institutions and do not apply to Medicaid.

Medicaid officials say that in the example of cardiac pain, if the ER physician determines there is no physical reason for the pain, the visit would be classified as non-emergency and not covered.

But if the physician determines all the right conditions are present for a life-threatening diagnosis, the visit would be considered an emergency and be covered.

"The ER physician is in charge of the process," Thompson said.

Expensive safety net

Hospital emergency rooms have long served as a safety net for people of little means without health insurance or access to care.

Starting about 30 years ago, experts say, many families got in the habit of taking their children to the emergency room for an earache or runny nose. More often than not, the care was covered by insurance or treated as charity if patients couldn't pay.

It's a difficult habit to break.

Survey data collected by Memorial and other local providers shows that many people are showing up at the ER instead of taking advantage of "help lines" offered by many local medical clinics during the day and after hours. Trained professionals are available to counsel a patient on whether symptoms merit an ER visit.

"A majority of people going to the ER are making their own judgment and not availing themselves of these services," said Dr. Mike Maples, chief executive of Community Health of Central Washington in Yakima.

To change that, the clinic is calling patients it knows have been seen in the ER to find out if they could have used the help line, possibly saving them from an unexpected bill.

"It's a lot of patient education," said Leslie Myrick, quality assurance and risk manager for Community Health.

Maples said the new policy was borne of budget considerations more than medical ones, but it's worthwhile to try to lower some costs while hopefully improving access to preventive care through the medical home concept.

"It's a blunt instrument to balance the budget, but we're trying to make some lemonade out of it," he said.

* Leah Beth Ward can be reached at 509-577-7626 or lward@yakimaherald.com.