Faced with rising Medicaid costs, most states are trying to come up with ways to save money. About a dozen states have proposed plans that would refuse to pay emergency room costs for patients whose problems could have been solved with a doctor office visit.
Proponents are basing their proposal on a widely held belief that people without private health insurance use public emergency rooms for minor or routine complaints. The supporters believe that this policy would encourage those individuals to get, and be treated by a primary care doctor where the care may be better and the price tag is cheaper.
The obvious problem that arises, however, is in figuring out how patients will know what is an emergency verses what can be treated with an office visit. As an NPR Shots article points out, people come to the ER with symptoms, not diagnoses. Opponents say that enacting a policy like this can discourage people from using the emergency room in cases where they should be there. Chest pains, for example, can be a heart attack or indigestion, but patients need to be in the ER if it is the former.
Under the Affordable Care Act, Medicare and private insurers are required to pay for emergency room visits that a “prudent layperson” would consider necessary; like the chest pains visit that turns out to be indigestion. Medicaid recipients, however, are not afforded the same protection.
One study cited in the article looked at the discharge records for 35,000 people that visited the emergency room in 2009. When researcher separated out the people that had primary care treatable problems, they were found to only make up six percent of all the records in their study. Additionally, the six percent of primary care treatable patients presented with the same symptoms as 89 percent of people that went to an ER.
Washington passed a plan to cut ER payments that was later overturned by the governor. Without state Medicaid programs paying, the cost for these ER visits would be passed on to the hospitals.