I write today in response to Public Notice – Intent to Amend the State Plan: Avoidable ER Claims and Hospital Readmissions. Chesapeake Regional Healthcare (CRH) opposes both proposed amendments.

Avoidable ER Claims:

CRH is an independent, non-state-owned public hospital. Our operating revenues are generated solely from the care we provide to those who are treated in our hospital. Over-reliance on hospital emergency departments for non-emergency or preventative care is a major problem, but it cannot be solved by penalizing hospitals for treating patients.

Under federal law (EMTALA), we are required to stabilize and treat any patient who seeks care in our emergency department. Reducing Medicaid reimbursements due to us will worsen our operating losses for uncompensated care, without having any impact on the number of patients seeking non-emergency care in our ER. Hospitals cannot control which patients seek care in emergency departments and cannot deny patient care based on the acuity of their condition.

Amending the State Plan to allow the pending, reviewing and reducing of fees for “avoidable emergency room claims” would also be inconsistent with the federal Prudent Layperson standard and existing CMS policy.

Rather than penalizing hospitals, it should be the responsibility of Medicaid MCOs to educate their clients on non-emergency options and to encourage them to seek urgent or primary care. Cases in which Medicaid patients may not realize their options for non-emergency care constitute a failure on the part of the MCOs.

Hospital Readmissions

This proposed amendment would modify the definition of readmission to include cases when patients are readmitted to a hospital for the same or a similar diagnosis within 30 days of discharge. When a patient is discharged, they are overseen by the MCO and are subject to several environmental and social determinants outside of a hospital’s oversight or control and can lead to a patient’s readmission. Other factors include the inability to afford medications; lack of coordination of support by Medicaid MCOs; lack of information from Medicaid MCOs on options for urgent and primary care – and others.

Medicaid MCOs are responsible for following up with members who were recently hospitalized, providing support, and assisting with prescribed outpatient treatments plans. Hospitals do play a role in reducing readmissions, but MCOs are primarily responsible for coordinating these services.

CRH respectfully asks that DMAS be prohibited from implementing these two policy positions.