THCB

Is It Time To Charge Medicaid Members for ER Usage?

No one would deny that we’ve reached a point in public healthcare finance where tough choices have to be made about what gets covered and what doesn’t. There is, however, one fairly easy choice, and that is to reconfigure the $3 copay for Medicaid members using the emergency room.

I would propose a replacement benefit of $0 for the first visit and $20 for each subsequent one, in a given calendar year. Not every state, but any state that reaches certain thresholds for physician access or urgent care availability may switch to this policy.

Here are the arguments in favor. First, each $3 visit costs the state and federal government about $500.  There are few discretionary or semi-discretionary patient decisions that cost so little to trigger so much taxpayer spending.  (Hospitalizations have that kind of ratio, but a patient can’t check himself into a hospital the way he can visit an ER.)

Second, one must consider the historical context. The $3 copay (“$3” is a shorthand for $0 to $10 — I don’t think it is over $10 anywhere) is a vestige of the bad old days when it was very difficult to find physicians who accepted Medicaid patients. That is still the case in some locales; they would not be eligible for this waiver. The world has changed, but the copay hasn’t.

Third, ER utilization rates in the TANF population, which because of its average age is generally pretty healthy, far exceed that of the commercially insured population. This is despite the fact that TANF members in general cost much less than commercially insured people, a gap that widens still further once birth events are removed from the calculation. Clearly there is much excess utilization.

Fourth, while avid readers of this blog may recall that I am no fan of North Carolina Medicaid, my objections are confined solely to their consultant’s math — Milliman USA embarrassed themselves and their client by coming up with obviously impossible conclusions. See here. By contrast, I do think they (meaning Community Care of North Carolina) have done as good a job as possible under public-sector constraints to enhance access to care for Medicaid members, and my hat goes off to them for the tremendous efforts they’ve made.

However, what we’ve learned from that experiment is that the best-designed network in the world won’t attract Medicaid members if the ER is basically still free. Yogi Berra called this one right:  “If people don’t want to come to the ballpark, you can’t stop them.”  For this model or any other access models to be given a chance to work (and to be given a chance to pay for themselves), member economics have to support the access strategy.

Finally, this is not a take-away. The proposal would be $0 for the first visit — a cost savings. And obviously if someone shows up for a second visit without $20 and it’s a true emergency, that person wouldn’t be denied care.  (It also may not be easy to check eligibility for the $20, but most of the value of this policy is in people thinking that they might be charged $20, and deciding to go to their doctor instead.)

All the old objections need to be discarded or can be addressed. Yes, transportation may be hard to come by but most doctor offices are more accessible than most hospitals. Yes, after hours doctor offices aren’t an option.  That could be addressed by a call to a doctor to clear a visit to the ER.

I’m sure there will be objections — the THCB regulars are nothing if not opinionated — but please make sure to propose an alternate way to save a large chunk of money involving more savings and less of a take-away.

Al Lewis, president of the Disease Management Purchasing Consortium, is author of the critically acclaimed 2012 humorous look at the innumeracy of health plans, consultants and vendors, Why Nobody Believes the Numbers.

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philliphttp://Narod-Prav.ru/node/6692/Finger pointingkelli beanJacqueline L. Jones Recent comment authors
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phillip
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phillip

I think all of you need to go the ER with only Medicaid. See how you are treated. I have had always had good insurance through my employer. I have a fiance’ who is on medicaid. She started having bad tremors which was a side effect of an anti-depressant. She couldn’t walk she was shaking so bad. They checked her vitals and everything looked ok. The Dr. walked in and told her she was faking. Oh and this was at Baylor medical center in Dallas. The little nurse said she didn’t think this was an emergency. Well if she was… Read more »

http://Narod-Prav.ru/node/6692/
Guest

It’s a pity you don’t have a donate button!
I’d definitely donate to this outstanding blog! I guess for now i’ll settle for bookmarking and adding your RSS feed to my Google account.
I look forward to fresh updates and will share this website with my Facebook group.

Chat soon!

Al Lewis
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Al Lewis

I think you are referring to some of the more recent comments, and may recall from the actual article 59 comments ago that I myself did not point fingers but rather (1) proposed a $0 copay for the first visit, which is $3 better than now and (2) suggested that only states meeting primary care access standards could qualify for that. I would certainly concur in your comments about reducing utilization for other large users by addressing their needs, but it shouldn’t be an either-or. You may be able to use savings from unnecessary ER visits for the worried well… Read more »

Finger pointing
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Finger pointing

Why do Medicaid ED visits attract anger and controversy disproportionate to the amount we spend on them? The highest users of healthcare dollars have frequent hospitalizations (they may go thru the ED but the point is that they are very sick and require admission) and/or require total long term care at home or in a nursing facility. There is a lot of reason to believe that we can reduce the huge expenditures on the very sick by addressing their needs (for example, search for Gawande’s article on hot spotters on the net). Spending on a single diabetic patient who requires… Read more »

MD as HELL
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MD as HELL

I am declaring victory.

kelli bean
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kelli bean

I agree with you good doctor.

MD as HELL
Guest
MD as HELL

MD as HELL is a 30 year physician in the same ED providing care to all who present themselves believing they have an emergency. Originally we screened out nonemergency complaints and sent them to an on-call physician who was oblidged to see them once without demanding payment. It worked until the feds passed EMTALA. The medical staff became less interested in playing ball and courts decided that anything short of treatment was not “stabilized”. In 1982 in a county of 100k population we had 18000 ED visits plus 6000 nonemergency screenins referred out. In 2012 we have 60,000 annual visits… Read more »

Peter1
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Peter1

“I am no Scrooge.”

Then come up with a more elegant solution instead of taking your bitterness out on Medicaid recipients.

MD as HELL
Guest
MD as HELL

In fact I am not. They are treated like pets. They have no accountability for their expenditures. They have no budget. They have no constraints. The soluton is to give them x dollars a year. What they do not spend they keep. the left howls that they will forgo needed healthcare and keep the money. That means they are treated like pets; incapable of determining what care they need on their own. Hence the disconnect between me and the left. You must treat them like equals and let them fail if they so choose. There children are theirs. Let the… Read more »

Peter1
Guest
Peter1

“They have no accountability for their expenditures.”

What expenditures, they’re the poorest of the poor.

“You must treat them like equals and let them fail if they so choose.”

They’ve already failed, that’s why they’re on Medicaid.

If you’re no Scrooge then stop thinking and speaking like one. Bring back debtor’s prisons eh MD, that’ll teach’em.

MD as HELL
Guest
MD as HELL

OK. Then let them have consequences instead of rewards. I do not believe they have failed. I believe they are smarter than the blogger who thinks they need all this help. The bleeding heart do-gooder who is blind to the scam.

Al Lewis
Guest
Al Lewis

Agreed

the original article (way up at the top of this thread) says you’d only do this in states that reach certain thresholds for physician access.

Doctors can preach all they want, but even commercially insured members rarely make the lifestyle changes they need to make. That’s why obesity hasn’t declined and smoking is declining only at a very slow rate.

Hence I think you’d have to set the standard for access more objectively than you are suggesting, unfortunately.

Jacqueline L. Jones
Guest

Medicaid patients can’t afford to pay more. That’s why they’re on Medicaid. And many times they can’t find a doctor who will treat them in an office because reimbursement rates for Medicaid patients are so low. One solution is to increase payments for providers who understand how lifestyle changes can prevent, reverse, or slow chronic illness. Advanced chronic illnesses are expensive.

Al Lewis
Guest
Al Lewis

Yes. I personally have programmed my computer so that his comments don’t show up.

btw I think there are only three of us left in this thread so I vote that we all declare victory and get out.

Al Lewis
Guest
Al Lewis

Doug, of course that’s what you said. This board is not moderated so there is no requirement that comments have to reflect adulthood in order to be posted. When I send this thread to my West Wing contacts, I’ll be deleting half of these comments.

d.d.
Guest
d.d.

My suggestion was to: (1) pay the provider (a fair rate) for providing an EMTALA screen, even if performed by a non-MD (2) allow them to not provide ED care if not warranted (3) strengthen legal and safe harbor protections for not providing care …. how does that “penalize the hospital” ? (Especially compared to the situation today.) In terms of changing patient behavior, my version of the scheme allows EDs to not provide care beyond an EMTALA screen, if that screen shows that no “emergency” exists. And strengthens protections against denial of care allegations. Someone not needing emergency care… Read more »

MD as HELL
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MD as HELL

Sorry. I just replid to an automated esponse in my email. your proposals also will not work.

#1. Care will retrospectively be determined to have not been needed.
#2. Denying treatment again will be retrospectively be determined to have been appropriate.
#3. When patients complain to CMS or DFS (in NC) there will be time-consuming investigations into those decisions.
#4. It still does no change the behavior of the culprits.

d.d.
Guest
d.d.

@Md as HELL: I disagree on #4 that behaviors won’t change, but I can see where there could be a concern on your first three points. You have a very valuable point there, that I did not think about. Those all relate to “compliance responses” that have been developed in response to real or perceived abuses under the current system of reimbursement and access. If policy makers significantly change the ED system in the ways suggested, then hopefully there would be a recognition that the old compliance mechanisms also need to be reviewed and modified, to make them appropriate for… Read more »

Peter1
Guest
Peter1

d.d., if you haven’t been on this blog for long then you fail to see that “MD as Hell” is a health care Scrooge who would like to see a Dicksonian health care system where children still worked in factories to pay for their health care and debtor’s prison is where we held those on Medicaid.

d.d.
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d.d.

Coming to agreement on system changes often requires acknowledging and addressing the substance of objections raised by affected parties, even if they come in a prickly wrapper.

MikeQ
Guest
MikeQ

There is a pony in this pile of proposals and comments, especially the last one. Anyone who doesn’t think that ED overuse in Medicaid isn’t a problem is simply wrong, and yes, being “free” and billboard signs and habit and perceived (and sometimes actual) lack of access all contribute. And in this thread are elements of an elegant solution. I might add two more things: (1) Reimburse at the urgent care rate for non-emergencies, like they do in Illinois (2) Track the hospitals against one another and investigate all “outlier” hospitals. Like with RAC audits, miscoding would be penalized.

MD as HELL
Guest
MD as HELL

Another m***n wanting to short the hosppital for doing it’s job.

Mcaid and the beneficiary need to do their job! Stay out of the ED with your whiny crap!!

d.d.
Guest
d.d.

hey, MD as HELL, it seems your goal of “stay out of the ED” is the same as the goal of @Al’s post and the other comments on this blog … would you mind enlightening us with a little more detail on exactly why you think these policy recommendations would not work?

Charm alone will not carry this argument.

MD as HELL
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MD as HELL

Penalizing the hospital does not change the behavior of either the patient or the politician.

Douglas Dame
Guest
Douglas Dame

This article and discussion is excellent. I think part of a satisfactory solution would involve: * Medicaid paying a ED “(facility) triage fee” for the EMTALA screening, even if done by an RN/ARNP/resident rather than an MD. If nothing is paid, then the financial incentives are for the ED to upcode to “real emergency” to get paid. Let’s not encourage that, and let’s not encourage cost-shifting the burden of EMTALA screenings onto the other patients. * clarification that if a reasonably diligent EMTALA screening for a true “emergency” is done, the hospital can and should refuse treatment, without liability. (I… Read more »

MD as HELL
Guest
MD as HELL

Great!! A m***n wanting to change behavior by conditioning the wrong party.

Peter1
Guest
Peter1

Yes, have them self diagnose with WebMD to see if they’re really sick.

Al Lewis
Guest
Al Lewis

Of course I would and so would most other people — it’s simple economics. Last summer I stepped on an oyster shell. It didnt’ realyl require an ER visit but I thought given the location of the cut it would be better to have a pro clean it out,. I was on the fence so I called the insurer to check my co-pay and called the ER to see if they were busy. The copay was “only” $50 and the ER had no wait at that point, so I went. Now make the copay $3 and add those billboards about… Read more »

Margalit Gur-Arie
Guest

I wouldn’t have gone, but OK, let’s assume that for the incidental minor cut and bruise people would go.
Regulators are requiring all sorts of things to be in place in a hospital, why can’t they require that every major ER has attached to it (not across the street or three blocks down) a simple urgent care facility, and patients are triaged accordingly (all patients, not just the poor ones) when they come in?

MD as HELL
Guest
MD as HELL

Typical solution: Someone else gets to sort out the chaff from the wheat. Who pays for the sorting? Do you think that will be free?

Most patients do not need the ED. Not just Medicaid patients. In fact most people do not need all this healthcare at all.

We need to stop turning healthcare into a religion.

Margalit Gur-Arie
Guest

Yes, it is a typical solution, because I don’t think we need any radical solutions for this, and no, it’s not free, but it should be significantly cheaper for all involved. The question, of course is whether “all involved” have any interest in making anything cheaper, as opposed to making things inaccessible for those who can’t pay exorbitant and unnecessary prices. And I agree with you that most people don’t need any of this stuff, so maybe “all involved” quit spending billions on advertising, construction and lobbying instead of spending it on what it was originally billed out for –… Read more »

Peter1
Guest
Peter1

This won’t get solved until health care spending gets treated as an expense and not as income.

Single pay with spending budgets would turn that mentality around.

MD as HELL
Guest
MD as HELL

But they do not need it.

BobbyG
Guest

“simple economics” are replete with totemic anecdotes, long on confirmation bias laden theory, and short on science, Al.

Margalit Gur-Arie
Guest

Maybe I’m reading this wrong, Al, but the OECD database does not show that we do more cardiac surgery that other individual countries in Europe, some of which seem to be on a stenting rampage…
http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#

Regarding the $3 vs. $500, would you go to the ER for a headache (or whatever), if it was only $3, or even completely free? Would you go more often to the ER in that case? If your answer is no, then there must be a different reason for this behavior.