Emergency Or Not? Ky. Medicaid Changes Will Penalize For Unnecessary ER Visits

February 26, 2018 2:32 PM | Sally Winkelman (Administrator)

NOTE: Wisconsin ACEP President Lisa Maurer, MD was interviewed by NPR and featured in the following article. The article inadvertently shows Dr. Maurer's affiliation with Ohio rather than Wisconsin. 

89.3 WFPL/HEALTH - February 21, 2018
By Lisa Gillespie

Starting July 1, some Medicaid enrollees could be fined for going to a hospital emergency room if they end up not actually having an emergency.  The new policy is part of bigger changes to the Medicaid program led by Governor Matt Bevin.

The penalties apply to adults who gained coverage after Kentucky expanded Medicaid, such as adults without dependents, or some parents who are in families that make between 54 and 138 percent of the poverty line.

“The intent of the policy is to reduce inappropriate emergency department use and educate individuals about the most appropriate setting for their health care needs,” Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, wrote in an email.

Medicaid, the state-federal health care program for low-income and disabled Americans, is paying for a bigger chunk of ER visits since the health insurance program expanded in 2014. In 2015, for instance, almost 47 percent of the ER visits in Kentucky were paid for by Medicaid, up from about 30 percent in 2012, according to a report by the Foundation for a Healthy Kentucky.

Here’s how it’ll work: Enrollees will be given a “My Rewards” account. If the state deems an ER visit as unnecessary, My Rewards dollars will be deducted from that account, ranging between $20 to $75. That account will also be used to earn “dollars” for dental and vision services, since these Medicaid enrollees are losing automatic coverage of those benefits.

Enrollees could also make a co-payment if they don’t have a My Rewards account.

If an enrollee calls their insurance company nurse hotline before going to the ER, that penalty will be waived, even if the ER visit isn’t for an emergency.

Here’s who could be affected:

  • Parents earning between 54 percent and 138 percent of the poverty line;
  • Adults without dependents.
  • Pregnant women, former foster care youth and enrollees who obtain a “medically frail” exemption will have access to a My Rewards account, but won’t face these penalties.  

Determining A ‘Non-Emergency’

There’s debate about what percentage of emergency room visits are unnecessary. The answer depends on where the information comes from.

Health care researcher Truven Health Analytics analyzed millions of ER claims from 2010 and found 71 percent of visits were avoidable or unnecessary. The American College of Emergency Physicians, meanwhile, says only about 3.3 percent of ER visits are “avoidable.”

There’s also a difference in how the state, an ER doctor and a patient define “non-emergency.”

“There are very few patients who come to the ER who truly know that they didn’t have an emergency right up front,” said Dr. Lisa Maurer, an emergency room doctor in Wisconsin.

Maurer understands that Kentucky’s new policy is supposed to discourage unnecessary ER visits but she worries it will deter patients who truly need to come.

“We want to make sure that our patients feel that if they’re having an emergency, they can come to the emergency department,” Maurer said, who is also on the state legislative-regulatory committee at the American College of Emergency Physicians.

Dr. Ryan Stanton works as a doctor in an emergency room in Lexington. He agrees with Maurer that people can’t always tell when something is an emergency. To regular people, conditions that a health insurer or an ER doctor might not see as an emergency, is to a patient, an emergency. Stanton used the example of patients with high blood pressure who fear they are on the verge of having a stroke. 

“We’re hearing on the radio these ads about blood pressure causing stroke, and you need to go to the ER right away,” said Stanton. “But blood pressure is rarely an emergency. But to the lay public, blood pressure is a stroke waiting to happen.”

A visit because of high blood pressure and fear of a stroke could be classified as a non-emergency if Stanton finds the patient wasn’t actually unstable or about to have a stroke.

An Emergency In ‘Access to Care’

 “How many people do we have that call the family doctor, and the receptionist says, ‘If you can’t wait three days to get an appointment with us, then just go to the ER?’” asked David Wesley Brewer, former president of the Kentucky chapter of the American College of Emergency Physicians.

Brewer said another reason people come to the ER, even if they know know it’s not an emergency, is because Medicaid enrollees have a hard time finding a primary care practice with immediate availability. The Truven Health analysis found that of the 71 percent of what it deemed “unnecessary” ER visits, more than 40 percent of those people could have been safely treated in a primary care setting.

And locally, at the University of Louisville Hospital, two thirds of ER visits occur after hours, when cheaper alternatives like primary care offices or free clinics are closed. And the vast majority of visitors, the hospital said, have either been directed by their primary care office/insurance nurse line to go to the ER, or have a time sensitive medical need.