ER Utilization Program

I write in opposition to the proposed ER Utilization Program due to take effect July 1, 2020.  This program will indiscriminately penalize emergency care providers and facilities for providing appropriate and needed care to Virginians who have the least access to care and will penalize all emergency department patients.

Our group of over 140 providers of emergency care is the safety net for these patients in Hampton Roads; 26% of the patients we see have Medicaid or a Medicaid HMO.  As care providers, we do not control when and how patients seek care.  The list of over 800 conditions in this program that will be arbitrarily down-coded to the lowest possible level of service regardless of the complexity of care required to appropriately diagnose and treat involves many potentially life-threatening conditions.  This policy violates the prudent layperson standard which has long been in effect in our Commonwealth.

While decreasing preventable ED visits is an appropriate goal so long as appropriate alternative care is available and accessible is a laudable goal, penalizing emergency providers who are bound by EMTALA law to evaluate all patients who come to the ED is the wrong approach and will ultimately further decrease access to care for and harm this vulnerable population.

Emergency departments , based on EMTALA law, must evaluate and treat all patients who present to emergency departments regardless of insurance status or ability to pay.  These evaluations often mandate very expensive and time-consuming tests.  It is absurd to down-code these situations to a $14.95 payment because no life-threat was found during needed testing.  If enacted, this program will cripple the ability of emergency departments to provide quality access to appropriate and necessary care.

It is inappropriate to place a patient in a position where they are expected to self-diagnose a concerning symptom to decide whether or not an emergency department is needed to diagnose and treat their complaint or whether they could see their primary care physician.

CMS guidance obligates state Medicaid programs and managed care organizations to reimburse doctors and hospitals appropriately for their legal and moral obligation to do testing and provide care to rule-out or confirm emergency life-threatening medical conditions.  The same presenting complaint can sometimes be due to a life threat and sometimes be due to a more benign condition.  Ex post facto down-coding of payment based on a list of diagnoses completely ignores the reality of the way emergency departments function.  This retrospective approach is punative to providers.

Patients will be negatively impacted in several ways:

--They may feel compelled to wait to seek care because they are concerned that their symptoms may not be deemed an emergency.  Thus the patient who has "heartburn" may not come to the ED and die at home from their heart attack.

--Dramatically reduced payments for services delivered will result in an inability to appropriately staff EDs.  This will lead to long ED wait times.  Those hospitals that treat a larger percentage of Medicaid patients, primarily hospitals in urban and rural areas, some of the hospitals under the most intense financial pressure already, will be disproportionally affected by this.

--Financial viability of emergency departments has been drastically altered by COVID-19 which has caused volume decreases by as much as 40%.  With the added financial burden of this legislation, many of these emergency departments could be forced to close, which will make seeking care far more difficult.  These closures are more likely to occur in urban and rural areas which will disproportionally affect minorities.

DMAS should halt implementation of this faulty program and should affirm and comply with the prudent layperson standard for emergency department reimbursement.