Like many other public comments, I wanted to emphasize that this proposed policy runs exactly counter to the "prudent layperson" standard that CMS has long had in place to keep patients from having to attempt self-diagnosis prior to seeking emergency medical care. It is not reasonable, fair, or rational to suggest that patients determine their exact diagnosis prior to the decision to seek medical care in an effort to ensure that they are not going to be determined to have an 'avoidable' diagnosis. Similar schemes have been proposed before (e.g. - Washington State, https://www.prnewswire.com/news-releases/washington-state-changes-course---upholds-prudent-layperson-standard-for-medicaid-emergency-patients-145801145.html), despite these running clearly and exactly counter to the prudent layperson standard that CMS lays out.

Several of the proposed diagnoses on this 'downcode' list are often associated with presenting signs and symptoms that could suggest a much more serious underlying condition. Transient synovitis of the hip can and does present very similarly to septic arthritis, and the more benign diagnosis of transient synovitis is often not known until after blood work, imaging, and potential arthrocentesis to analyze the fluid in the joint space for direct findings of infection are completed. In other words, a child with a fever and a non-traumatic limp could have either diagnosis. The parents, nor the physician, know what the diagnosis will be until after a thorough Emergency Department workup commences. The family should not be asked to attempt self-diagnosis instead of presenting for emergency care in such a scenario. Delays in treatment for septic arthritis are linked with permanent joint destruction and death. Many other diagnoses on this list follow a similar theme. 

There are better ways in which to accomplish the legislature's goals. Trying to work around the prudent layperson standard is not the way in which to reduce expenditures long term. Please consider the harm to medicaid patients and our emergency care network that this short sighted policy will have.