The future of medicine in Washington State

[ERDoc]

So the great state of Washington has decided that it's medicaid program will not pay for non-emergency ER visits, leaving the physicians/hospital with the bill and liability. We won't begin to discuss the stupidity that went into deciding what is considered "non-emergency) (DKA coma anyone?).

http://hrsa.dshs.wa.gov/News/Fact/NonMedicallyNecessaryERVisitsFAQ.pdf

So, how is this relevant to EMS? I think we are on the precipice of a very slippery slope. For now it is the ER, next year they may decide not pay for non-emergent ambulance rides. What do you guys think?

Maybe someone can tell me where to purchase a good retrospectroscope?

[DFIB]

It sounds like they want you guys to work longer for less. The logistics are going to be a nightmare.

[paramedicmike]

Wow.

Just wow.

So how do you see this playing out? Will ER fast tracks turn into screening services simply to direct people into the ER or turn them away? This might be creating more work but could a fast track be deemed a primary care service so as not to lose out on the billing while still providing care for patients?

Everybody's looking for ways to save a couple bucks. But this just sounds dangerous. And stupid.

[Kiwiology]

Oh my god what in the bloody hell, have these people going mentally insane like psychologically in the noggin?

Words are inadequate to describe the immense level of super-mega fail here; nothing in the fabric of the space time continuum or the known facilities of science-based-medicine (phosphofructokinase anyone?) even begin to pale in comparison with the uber nunngered brainboxology of this idea; not sweet as bro; not sweet as at all; pretty stink bro; no ghost chips required!

This is even more nunngered than phosphofructokinase or why the two [H⁺] pumped from the mitochondria when Complex IV of the electron transport chain tip the electrochemical gradient so ATP Synthase can phosphorylate ADP and Pi into ATP when eight, yes read them, eight hydrogen protons (ions) are pumped out of the mitochondria by Complex I, II and III .... eight is a bigger number than two people!

Wait just a second, this almost sounds dangerously like educated synthesis of information that comes from a ... a. ... a biochemistry book, if I keep this up I'm going to be burnt at the stake for being a witch or some shit ....

Anyway, what were we talking about? I got side tracked ... oh yes, this idea is pretty buggered in the noggin bro, seriously; where are people supposed to go to get this "non emergent care"; what if they don't have a GP? The GP has no appointments? They have no insurance? The GP is 20 miles away and they have no car? Their GP told them to go to the hospital because said GP has not seen a sick person since their House Officer year when Semmelweis and washing your hands was considered the latest advent in medicine?

Research here (and I think in AU too) shows that most people (exceptions apply) who go to ED actually need to go to ED and receive hospital services like diagnostic testing or sutures or something that their GP can't do (this is why the (UK) NHS Minor Injuries Centre and Walk Ins are great they can do stuff like that ... anyway) ....

And just how is that dangerously overworked, underfed and fatigued House Officer doing his ED rotation expected to pay for his crippling $300,000 student debt for four years of medical school (when five here costs us NZ70,000 mwahahahaha!) if nobody pays him ... and let's not forget those Consultant Emergency Physicians like their fast cars and boats too y'know

[DFIB]

Another crippling factor is that because of the bureaucracy and difficulty in billing and getting paid by Medicaid fewer and fewer GPs will receive Medicaid for billing. The majority (I say majority from observation and not a statistical study) of Medicaid patients opt for Health Dept. clinics or clinics run by Practitioners and PAs.

There is nothing wrong with these clinics but the idea that GPs are going to jump at the opportunity to boost their Medicaid clientele is flawed. Most businesses almost need an entire separate billing department just to track Medicaid refusals and resubmit for payment.

[DwayneEMTP]

I'm guessing that they've made this decision without also adding the ability to triage non emergent patients to their PCP?

What's truly frustrating about this kind of shit is that it won't make a dent in the misuse of the ER. Several years back I went in for laryngospasm...$3k for my uninsured visit, paying for the time in the ER/doc, an IV and half a cc of Glucagone.

None of the non payers will stop going to the ER, it will just cost me $6k next time.

Limitting money without increasing triage ability is just craziness...

The one thing that sometimes makes me a little crazy about street medicine is the constant hauling of non emergent, never gonna pay patients to care that I can't possibly afford for my family...Not a lot crazy...only in my weaker moments... :-)

Welcome to government subsidized.....anything....

Dwayne

[ERDoc]

So now we are not going to be paid for seeing pts that the govt requires by law that we see. We didn't ask the pts to come in and have no say in whether or not they come. We are supposed to turn them away, with no extra litigation protection, to see a PCP even if they don't have one. We will also have to see those that called their PCP and were told, "Just go to the ER." The state is going to decide, after the fact, if there was a need for an ER. Talk about a perfect storm. I realize that this only affects the state medicaid pts, but like I said, it is a slippery slope.

[DwayneEMTP]

What percentage of patients would you guess would fit into the state Medicaid patient population?

[ERDoc]

What percentage of patients would you guess would fit into the state Medicaid patient population?

According to http://www.washingtonpolicy.org/publications/legislative/health-care-freedom-washington-state there were over 1.2 million people in Washington on medicaid and I can't imagine that number is any better now. As for what percent of an ER population is part of the medicaid population, that is highly variable from ER to ER.

[Bieber]

This is a perfect example of an unsustainable business model, and if it trickles its way down to the ambulance services, I can't imagine how they will be able to stay afloat. If they provide 911 services, they have to transport any patient who requests it, and unless Washington is going to create a mechanism that allows EMS providers to refuse transport based on the patient's condition, they're going to get screwed over hardcore.

I'm all for incentives and mechanisms to prevent and avoid unnecessary hospital admission and readmission, but what they're doing is telling folks to work for free--and that is simply not feasible.

EDIT: After reading the linked article, I notice that hospitals will be paid a screening fee so that hospitals are paid for the assessment of the presenting patient, so that's good and I think that this kind of system that deters non-emergent patients from the ER is appropriate. The problem is just that such a system won't work for ambulance services unless mechanisms are in place to allow EMS providers to refuse to transport a patient.

EDIT #2: I also notice that there is little clarification or extrapolation on what systems will be established to ensure that medicaid clients receive adequate primary care. Without providing primary care options, the elimination of the ER from the already limited list of resources available to medicaid/low-income patients may end up being detrimental. There needs to be more options available to those on medicaid to receive the right kind of care in the right kind of setting.

Edited January 15, 2012 by Bieber