Unfortunately, this bill is shortsighted at best, and negligent and immoral at worst.

Imagine someone’s beloved grandfather or father is mowing the lawn, he probably shouldn’t be doing it by himself at his age, but he’s a do it yourself kind of guy and likes to get outside. He takes his time, but by the end, he’s a little hot and he’s sweatier than he should be. On the last lap he developed chest pain. He comes inside to cool off, he drinks a glass of water but the pain hasn’t gone away. He tells his wife, and as a prudent layperson, she (and him) decides they need to go to the ER.  They are quickly triaged and placed in a room. His name, age, and chief complaint shows up on the track board. The nurse makes sure to tell you after you see him on the computer that he looks a little pale and sweaty. Immediately you’re worried this could be a heart attack, blood clot in the lungs, or one of a dozen other dangerous etiologies. He becomes the priority, even though you’ve been preparing to see a young boy with a severe earache for close to an hour (otitis media, preventable list). You come to the door to eyeball him as the nurse checks him in. You say hello and tell him you’ll be right back with him. You ask him if he’s still having pain, he is. You order some tests, an EKG, bloodwork including a heart enzyme, and chest x-ray. You review his chart, see he has cardiac risk factors. You finish up loose ends on a patient with severe abdominal pain. You’ve been working intermittently with this patient for the last several hours. You’re worried she has an acute abdomen and consult surgery, because after all an acute abdomen (on the list of diagnoses deemed preventable) is a life threatening emergency, and needs to be in the OR. You jot notes in the computer while holding the phone to your ear and talking at the same time. You work as quickly as possible because you want to get back to see the older man with chest pain. His EKG seems normal for now. You’ve given him some nitroglycerin and aspirin, and his pain has resolved slightly. You get the story from them, explain what you’ll do, what to expect in the ER, and what he or his wife should warn you of while they’re there. You see several other patients while waiting for the bloodwork and x-ray to appear, keeping an eye on his room hoping to catch the x-ray tech with the portable machine so you can look at the picture more expediently. You finally see them and wait just outside the room as she sets up and takes it. While it would be an unusual presentation, this could be a tension pneumo, aortic dissection, lung cancer, or pulmonary embolism. To your relief you see the x-ray’s basically normal with a couple of small nodules at the left base. You’ll try to compare old films to see if these are new or old and unchanging so you don’t have to worry this man and his loved ones unnecessarily with the “C” word. Back to other patients while keeping an eye on the board for the bloodwork to return. His initial heart enzyme comes back negative. Due to the timing of cardiac protein elevation, he’s not in the clear, but it’s slightly relieving that it hasn’t started rising yet. You go in, sit down and explain to him and his very worried wife your findings thus far, along with your general concerns and suspicions. You explain about the nodules you found, that they’re new but they look benign and he will need follow-up testing. He doesn’t want to stay but his wife wants him to. You gently explain with his history of diabetes, cholesterol, hypertension the risks are not in his favor. He needs a further workup to conclusively prove that he’s not having a silent heart attack. He will be admitted for further testing. In the end, after a stress test, serial enzymes, and CT scan, his chest pain is actually chest wall pain called costochondritis, inflammation between the ribs. You’ll net about $9.50 after taxes for the 2-4 hours you spent thinking about him and his potential disease becoming your stress. You were only in the room for 20-30 minutes, plus another 10-20 minutes charting and reviewing, and maybe 5-10 more minutes calling consults. You will probably check on him the next day in the chart to see how he did. You always do that for free anyways so that time doesn’t count.

The other time matters, and in a busy ER it matters more. If DMAS is going to decrease reimbursement for a vast majority of cases based on retroactive analysis of the diagnoses patients will get less and less time, and more mistakes will be made. More people will be pushed out the door without thorough treatment and discussions. The niceties will go away. Patients who have no other outlet will be kicked out without treatment because it wasn’t “life threatening.” This will be necessarily because you’ll need to see 40 patients a day in order to cover costs. 

Most physicians will have trained 12+ years to do this job. Some have hundreds of thousands in loans, not to mention the opportunity cost of not making a salary for around a decade. 

Should we punish the mechanic who tells you that you’ll need to have your entire engine replaced, then does it to the tune of $3000 and retroactively decides that this could’ve been avoided had oil changes been done sooner by another mechanic back in your hometown. I guess we’re only going to give him a third of the cost of the oil change, $14.98, but don’t forget to pay taxes on this, both state and federal, now $9.50. No, that would be insane and criminal. DMAS is asking us to take care of people that could potentially die for a third the cost of an oil change. I have personally taken care of multiple COVID patients and their final diagnosis has been on the list of the 17 pages of “preventable” conditions. I cannot hug my children or wife when I come home until I decontaminate. If I don’t shower at work I have to strip outside. The neighbors are starting to wonder.

Diabetic ketoacidosis without coma, not emergent. Come back when you’re in a coma then we can afford to pay the doctor to take care of you. Who cares if this patient is going to go to the intensive care unit. DMAS thinks a primary care doctor didn’t do their job right so they’ll punish the ER.

During a current healthcare crisis this policy is so shortsighted it seems about as intelligent as taking the wings off of the plane to save weight in flight. First this will punish emergency physicians and they will not be able to work. New residents will choose other specialties. Then it will punish hospitals and ultimately the patient in the end. 

For the first time in my career, I’ve seen the nation take an appreciation in emergency healthcare, to the degree that I think they should as we cover all holidays, weekends, 24 hours around the clock without pay that is commensurate to that level of work and commitment. We are expected to deal with any condition, at any time that rolls through the door, whether they will pay for our services or not. We don’t ask what or if they have insurance (DMAS is trying to change this). We quite often deal with the least educated and most disenfranchised segment of society, while they are feeling sick, this often makes them less than civil. We have all had more than one type of body fluid weaponized in our direction. We deal with society’s drunks, homeless, mentally unstable, drug addicts, rape victims, child molestation victims, and child and elder abuse cases. It is a shame that as the nation begins to recognize the importance of emergency healthcare, DMAS has gone the other direction to, at best, fly blindly with a short-sighted and reckless policy that will cost lives as hospitals are forced to restructure to cut care for Medicaid patients, as they will not be able to afford to stay open otherwise. At worst this is disingenuous, immoral, money grab, and a direct slap in the face to ER providers when we are most needed.