Washington Drops Plan to Deny Payment for Unnecessary ED Visits

Washington State Health Care Authority has dropped it's plan to deny medicaid payments for Emergency Room visits deemed "unnecessary," after intervention from the state legislature.  


The plan was a looming problem for Emergency Departments in the state. The "frequent flyers" who use the ED the most would no longer be compensated. That would have been insult to injury: the not-sick patients would have also been the ones that getting uncompensated treatment. A small number of these patients amass dozens to hundreds of ED visits every year -- mostly for things that did not require an ED visit. 


The plan was misguided because the law says everyone has a right to treatment in the Emergency Department. We can't turn anyone away without evaluation by a provider. Moreover, we have little control over the poor decision making or our customers.  This plan would have punished the hospitals for the public's overuse of the ED. Sure the patient would have been stuck with the bill, but hospitals would have had little expectation of payment. 


The new rules were supposed to go into effect April 1, but that was put on hold until an alternate plan passed through legislation. The new guidelines require hospitals to adopt seven best practices to help reduce frequent ED visits. (Listed Here, clipped from Washington ENA's newsletter.)

• All hospitals will have an electronic health care information system in place to share information on patient visits, case management plans, & flagged warnings.
• Hospitals must have literature in the department to discuss alternative care options.
• Hospitals must identify specific personnel as contact links to the HCA to receive & share information on patients requiring coordination (PRC), care plans, etc.
• ED providers must be in-serviced on "Patients Requiring Coordination" which is currently a list of about 5,000 HCA patients flagged as "over users" of Emergency services.
• ED's utilize the WA State Guidelines for Narcotic prescriptions for non-cancer chronic pain.
• ED Providers must document having signed onto the WA Prescription Monitoring Program to review all narcotic prescriptions written in the state for a patient.
• All hospitals must have a system to compile case management statistics to track success & compliance with the "to be determined" tracking points for quality improvement.

Better education and intervention with frequent users may help. Better access to primary care and better communication and patient education would help even more. 


Of course, it is not just the poor and uninsured using the ED for unnecessary care. Studies have shown that people with insurance have also increased their use of the Emergency Room.


"So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves?" wrote  Zachary Meisel and Jesse Pines in Slate Magazine. "The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care."


Often, when I am treating people, I find that they saw their primary care provider that day, and just didn't like the answer they got, or having to wait for test results. Even with longer wait times, the ED is like a fast food restaurant compared with making dinner at home -- quick, no reservations, minimal effort involved. 

Nurse advice lines after hours all seem to tell people to go to the ED to avoid the lawsuit that would follow if someone really sick was told to wait until morning. Communication and Education of patients are not compensated under the current system of care, but they could help avoid millions of dollars of ED charges.


Less than half of Emergency Department visits are for emergencies, according to a 2003 HSC study. A CDC study puts then non-emergent level at closer to 12 percent - it all depends on how you define emergency. As more insured and uninsured people use the ED for basic health care, waiting times get longer, and consequently the perception of quality decreases.  Guess what? Medicaid compensation is now going to be tied to patient satisfaction surveys.  

For more information on the proposed new guidelines, check out the following websites:

Washington ACEP

Washington State Hospital Association

Washington State Medical Association

Washington State Health Care Authority

Here's some links to studies on ED use:
CDC National Health Statistics Report 
Health System Change Report from 2003
Slate: The Allure of the One Stop Shop
Slate: Are Most Emergency Room Visits Really Unnecessary?
Ten Most Common Reasons for an ER Visit

Questioning Medical Tests (Demanded By Patients)

How many times have you found yourself explaining to patient why a certain tests is NOT being done. 

I do this all the time. So many patients walk in the door demanding one study or another (regardless of the cost) and are offended when they are told it is not necessary. 

Some recent examples:
1) A father who came into the Emergency Department with his daughter who had hurt her ankle when she stepped off a curb. He wanted an MRI when the Xray showed that it was likely only a sprain. 

2) A 22 year old woman who saw her PCP earlier in the day for "chest pain." She was told to take Advil, but she came to Emergency wanting and EKG, CT scan and blood work. 

3) A mother who had two daughters in a car accident. While they refused evaluation and transport on scene, the came into the ED by private vehicle. I had to explain why one patient needed a head CT while the other did not. 

As you can see, some of the these cases are indeed easier than others. 

 I often have to explain the costs, risks and benefits of certain tests to patients and patient families who insisted they were not getting good care unless ALL the possible tests were done and done RIGHT NOW. 

Indeed, we often see patients coming into the ED not because they can't get into their primary care provider for their non-emergent condition, but rather, because they saw their PCP THAT DAY and were unhappy with the result. These days patients demand tests they've heard about on TV or from friends and family and they are often disgruntled if they don't get them.

Oh, and medicaid compensation is going to be tied to patient satisfaction. Just thought I'd mention that.

This week a group nine medical societies released a list of tests that doctors should think twice about automatically ordering. You can check out the lists at Choosewisely.org. 

Dr. Christine Cassel, president of the American Board of Internal Medicine told MSNBC and that the idea is to reduce medical costs while doing no harm to patients. They looked at the tests that have the least benefit but that are routinely ordered per course.

"We all know there is overuse and waste in the system, so let's have the doctors take responsibility for that and look at the things that are overused," Cassel told MSNBC. "We're doing this because we think we don't need to ration health care if we get rid of waste."

Moreover, the unneeded tests often cause harm -- in radiation damage to the body, or needless suffering. Some tests can prompt doctors to take invasive procedures that cause more damage to the patient than improvement. Routine PSA tests -- as reported earlier this year -- is another example. Even the researcher that helped discover PSA says that the negative impacts of the overuse and misuse of this screening tool has lead to incontinence and impotence in many men with no decrease in cancer deaths.

"I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster." Richard J. Ablin wrote in a New York Times Op-Ed. "The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments."

The problem has a lot to do with patient education. Patient education is hard because you are often telling someone something they don't want to hear. Often you are telling a patient with abdominal pain that we don't know what's causing it. Often you are telling the family member of a cancer patient that any further treatment is likely to cause more suffering without increasing any chance of survival. Sure some tests are ordered to shield doctors from lawsuits, but doctors also have long memories of missed diagnoses. They remember the one time they didn't order that one test and left a disease undetected. 

Will these new lists help? It certainly will lend support to providers who are trying to make the right decisions about what is best for patients based on science rather than social pressures. 

Yet patient education -- something the American healthcare system doesn't do very well right now -- is going to have to get better. 

Being a nurse is all about advocating for your patients. 

Yet, sometimes advocating for a patient means not giving them what they want.