Limits on Emergency Visits by Washington Medicaid Patients are Dangerous and Will Increase Costs, Physicians Say

Sep 13, 2011, 15:12 ET from Washington State Medical Association


SEATTLE, Sept. 13, 2011 /PRNewswire-USNewswire/ -- The state's new plan to limit Medicaid patients to three "non-emergency" visits to the emergency room each year will put the most vulnerable members of society - including children - at risk of serious harm, according to the Washington Chapter of the American College of Emergency Physicians (WA/ACEP), the Washington State Medical Association (WSMA), and the Washington State Hospital Association (WSHA).

The state is taking away coverage for more than 700 diagnoses that have symptoms of serious medical conditions, including chest pain, abdominal pain, miscarriage, and breathing problems. While the state classifies many of these conditions as "non-emergent," physicians and health care experts do not agree. The list of conditions the state is adopting was generated solely by the state Medicaid office over the objections of physician and hospital task force representatives.

"The symptoms of many of these medical conditions indicate life-threatening emergencies, and people with these symptoms should seek emergency care," said Stephen Anderson, MD, president of Washington ACEP. "Not doing so could lead to severe illness, disability, and even death. Including conditions such as congestive heart failure, kidney stones, miscarriage, chest pain, and asthma is outrageous and dangerous."

Doug Myers, MD, president of the Washington State Medical Association agrees. "Severe chest pain can be a symptom of a heart attack or an esophagus problem that is not an emergency – but the patient cannot self-diagnose," said Myers. "Limiting Medicaid patients to three emergency department visits poses a significant threat to patient safety, leaving many to avoid or delay seeking needed emergency care in fear it will be deemed a 'non-emergency' and they will exceed the allowable limit. The end result of this kind of policy will be the need for prolonged and more intensive care, which not only harms the patients, but increases costs for everyone."

The legislatively enacted policy unfairly targets children and the most vulnerable citizens in our state. Two-thirds of the state's 1.1 million residents covered by Medicaid are children. The proposed plan would significantly affect them.

"Parents face the real danger of having a child who cannot breathe due to their asthma and having to choose whether or not to seek care in fear of being told their visit was not an emergency," said Dr. Anderson. "This is not right to ask of parents or fair to their children."

Prudent Layperson Standard
The plan, which was developed by the legislature and signed by the Governor as part of the 2011-2013 state budget, undermines the "prudent layperson standard" under both federal and state law. These standards require health plans to cover visits to emergency departments based on an average person's belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis.

The prudent layperson standard in federal and state law is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with acute care or a non-emergent medical condition. The prudent layperson standard addressed the severe problem of retrospective denials of emergency care by health plans and protected patients from having to self-diagnose their medical conditions out of fear of receiving a bill when they sought care for symptoms that are often emergent and life-threatening. The federal standard also required Medicaid managed care plans not to set limitations on the number of emergency visits that Medicaid managed care plans pay.

The new policy means that Washington Medicaid fee-for-service clients will not receive critical prudent layperson protections that are required for patients of all Medicaid-managed care plans across the country, all private health plans as mandated by the Patient Protection and Affordable Care Act, and all federal military and civilian employees mandated by a Presidential Executive Order. And unlike all other citizens in the state, Medicaid fee-for-service clients who suffer chest pains, or any one of more than 700 conditions, cannot know if their care will be covered and will thus be discouraged by the state from seeking care that could be needed to save their lives.

"We are not blind to the budgetary challenges facing our state," said Dr. Myers. "We expected to work closely with state officials to come up with a list of truly non-emergent conditions. But we are not willing to sacrifice patient safety and many of these cuts pose a dangerous and significant threat to the safety of our patients."

"There is a real possibility of expensive litigation against the state for implementing a plan that on its face contradicts federal and state law," said Nathan Schlicher, MD, JD, practicing emergency physician and healthcare attorney in Tacoma. "It is our duty to protect our patients, while caring for them in the emergency department and now we may have to do so in the court room. The state has gone beyond the legislative language in creating this list and it is our responsibility to protect our patients."

"It is bad policy to limit emergency room visits, and it could result in severely jeopardizing the health of people who need emergency care," said Dr. Anderson. "Medicaid patients with serious, multiple or chronic health care conditions, who often have the greatest need for emergency care, will be placed at greatest risk. There also is no indication that it would actually save the state money, though it would accomplish the goal of discouraging sick people from seeking medical care they desperately need."

Washington ACEP represents over 650 emergency medicine physicians and is a chapter of the American College of Emergency Physicians, a national medical specialty society representing emergency medicine. WA/ACEP is committed to advancing emergency care through continuing education, research and public education.

The Washington State Medical Association's vision is to make Washington the best place to practice medicine and to receive care. The WSMA represents over 9,000 physicians throughout Washington state. For more information about the WSMA, please visit

SOURCE Washington State Medical Association