A new reimbursement policy contained in Virginia’s biennial budget is reducing Medicaid reimbursements for emergency care if the visit is deemed, after the fact, to be “preventable.”
Nearly 800 emergency conditions are listed on the Virginia Department of Medical Assistance Services’ (DMAS) "Preventable ER visits" code list. Most of these conditions present to Virginia ERs as potential emergencies every day and would be automatically down coded. Examples include diabetic ketoacidosis, status asthmaticus, and abdominal pain.
Virginia ACEP spearheaded an effort to appeal this, and along with the Medical Society of Virginia and hospitals sent a letter to the Centers for Medicare and Medicaid Services and the U.S. Department of Health and Human Services asking them to review the policy using CMS guidance and recommend a reversal in Virginia.
Emergency physicians and hospitals cannot control when and why patients seek care, nor can we turn anyone away. We agree that we must continue to improve access to primary care and help prevent Medicaid patients from getting sicker, but that goal is not achieved with this policy. Instead, we should be improving coordination of care at all levels, including the Medicaid Managed Care Organizations. Denying payment for care that was rightly provided in the ER is often the result of the Medicaid MCO failing to manage care of their enrollees.
How this issue impacts physicians
Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.
Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare.
How this issue impacts patients
Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.
How this impacts health equity
While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because:
Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.
The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.
Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in the COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival.
Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.
Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.
How this issue impacts hospitals and health systems
Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes. Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations.
VACEP asks that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians.
