• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

Patients should never,ever,  be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.

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Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.

Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare. 

How this issue impacts patients: Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.  

How this impacts health equity:

While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because: 

Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

How this issue impacts hospitals and health systems: Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes.  Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations. 

We ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians

3000 words.

The proposed changes to reimbursement for Emergency Department utilization would significantly impair long term access to emergency care in Virginia. Emergency Physicians take pride in being available to treat all patients at any time of the day or night. Furthermore, we are legally required to evaluate all patients who seek our care. From life threatening emergencies to minor inconveniences, we resolve to be a constant safety net for our communities. 
If this new fee schedule goes into effect, it would put large holes in that safety net. Included in the list of diagnoses that would be down coded includes true life threatening conditions such as diabetic ketoacidosis and status asthmaticus. Patients with those conditions consume considerable amounts of time and resources. The ability to be reimbursed less than $15 for such a visit would lead to issues being able to fund the department. 
This would undoubtedly lead to budget cuts and staffing reduction, which would affect all who seek emergency medical care. 

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

Down coding this list of so called preventable visits will absolutely harm patients on many levels including fear of coming to the ED - we are already seeing that the patients who tried to avoid  the ER during the COVID19 pandemic are coming in grudgingly but are much more in extremis and sicker than if they had come in sooner. In addition, with shifts towards tele health visits, we are often the only people who can do a physical exam on these people to determine if an emergency exists. This program will only serve to harm physicians, ERs and patients. You can and should do better. 

I practice emergency medicine to help whomever needs help at any time of day or night. Many patients delay getting care because they are concerned their insurance won’t cover it so when they finally do present to the ER they are critically ill. Passing this bill will further hinder people from seeking help which will not only cost more in the end, worse  it will cost lives. 

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

I strongly ask that the state NOT to implement the ER utilization program.

How this issue impacts physicians: Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.

Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare.

How this issue impacts patients: Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list. 

How this impacts health equity:

While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because:

Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival.

Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

How this issue impacts hospitals and health systems: Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes.  Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations.

We ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

While I understand the concerns of the legislature for people attending the Emergency Department for a stubbed toe or a simple cut that could be safely treated at home and applaud their efforts to contain healthcare costs, I feel strongly this bill will not achieve those aims.

Patients can not be expected to tell the difference in advance between benign and life-threatening causes, for many symptoms. These include chest pain, belly pain, fainting, headaches.

I have two degrees, eight years of post-graduate training and am board certified in Internal medicine and soon to be certified in Emergency medicine as well. I still can not tell a lot of the time if a patient has a life threatening condition when they first walk through the door.

If you wish to reduce stress on overburdened departments, help set up free/low cost primary care clinics so that diabetic patients can have access to care before they have DKA. So that patients can be treated for their blood pressure and high cholesterol before they have a stroke or heart attack.

Fight the insurance and drug lobby that contribute to higher costs and make old previously cheap medicines like insulin, Epi-pens affordable. Insulin was life changing when we managed to manufacture it in the early 20th century. The Epi-pen was develop by the military. Now they are used to line the pockets of the rich at the cost of the lives of the poor. The increased cost of IV acetaminophen (Tylenol) contributed to the rise in opiate addiction as you can’t give a vomiting person a pill. But hospitals restricted IV Tylenol due to cost - it is literally cheaper to give them morphine, dilaudid or fentanyl.

Putting more money into preventing severe illness, like kidney disease, before it becomes so bad that you need dialysis, will save the government money in the long run. Patients on dialysis often struggle to work due to their illness and time spent receiving treatment. They then need disability assistance, Medicare/Medicaid and if they stop working, stop paying taxes. Help them to stay healthy, and you save money in the long run.

This bill will defund the last safety net left in the US healthcare system. We (the ED) are the only doctors who CANNOT refuse to treat based on insurance coverage. And we shouldn’t stop doing that. But this bill will further erode our funding and people will suffer. 

As I read the proposed modifications, the absurdity of the situation made my head spin.

Many of these patients DO utilize the ED routine precisely BECAUSE Medicaid does not pay enough to primary care providers to make it worth their time and medicolegal risk to care for these medically-complex and financially underprivileged patients.  Many of my Medicaid patients tell me that they are UNABLE to find a primary care provider who will take care of them due to their insurance.  Thus, they are unable to get timely preventative care and prescriptions that would keep them out of the ED.

Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

Now, with this proposal, you would hamstring the financial viability of the only place many of them can go for care?!?!

The diabetic who cannot get a doctor to write his/her insulin presents to the ED in DKA, who can only afford cheap food and not fresh vegetables,  requires thousands of dollars of care just to stabilize them, and you propose to pay the provider $14.98?

The asthmatic who presents in distress, requires oxygen and multiple rounds of life-saving medications and a 23-hour Observation in an overcrowded ED just to make sure they do not suffocate and DIE, and DMAS proposes to pay the provider $14.98 just because it was deemed by some bean counter that the visit was "preventable" in some idealistic rainbows-and-unicorns world?

By the time these patients present to the ED, the horse is out of the barn, the barn is on fire, and the earthquake has caused the cliff it was built on to crumble.  Yet you would only pay the contractor $14.98 to rebuild the barn because the fire was "preventable"?!?!  In what world does this make sense?

Federal EMTALA requires the ED to see AND STABILIZE patients who come to the ED for care.  Beyond the legal requirements, that is just the right thing to do.  That stabilization can cost hundreds or thousands of dollars, but you MUST realize the the ED is damage control.  We are tasked with fixing problems that have already occurred.  We are the EMERGENCY Department, not the PREVENTION Depart.

Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare. 

Stop this bill. Insurance companies are punishing both providers and underserved / at risk populations. 

Many of these "preventable" codes need emergent evaluation.

Healthcare is not a self service industry. If you want to stop more preventable cases, then properly fund and support primary care. Don't underfund and punish patients when you leave them no choice.

Thank you,

David Nesbitt MD

The proposed ER Utilization Program is disrespectful to emergency physicians who stabilize and treat all manner of urgent and life-threatening conditions, as required by EMTALA law, as well as to patients who are expected to manage their own care with insufficient outpatient support and self-diagnose emergent vs nonemergent conditions. The "preventable" diagnoses list include codes for severe asthma with exacerbation and diabetic ketoacidosis, which are not only frequently seen and treated in the ED, but often admitted. If these patients do not get emergency care, they would likely die. Other codes on the list include Bell's Palsy, which a prudent layperson would likely assume to be a stroke, and thus warrant emergency evaluation. Another is right lower quadrant abdominal pain, which would raise concern for appendicitis in both laypeople and physicians, until proven otherwise by a full ED evaluation. Other codes include poisoning in pregnancy, projectile vomiting, and various abscesses - where should patients go to have these problems attended to, if not the ED? How are any of these visits preventable? Hospitals and physician groups who primarily serve Medicaid populations will be significantly affected by reduced rates, which would have a huge negative impact on their ability to serve their patients, further widening the equity gap in medical care. Don't cut reimbursement for the providers who care for the least well-off in society.

To decrease reimbursement to the ED for "preventable diseases" such as an asthma attack or DKA makes no sense. First of all, the ED is not responsible for primary care and the long-term management of these chronic conditions. Additionally, a lot of these "preventable" conditions such as an asthma attack are not preventable! Asthma exacerbations are an expected and normal component of asthma. 

ED physicians are dedicated to treating all patients equally, and this bill would dramatically decrease our ability to stabilize life-threatening emergencies experienced by our patients. 

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

stop this legislation 

In a time where our minority populations need support this legislation could severely decrease their health. Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians and hospitals are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

Base the reimbursement on the presenting symptoms, not the final diagnosis. It is very difficult for the average person to know if the chest pain they are having is a heart attack or indigestion.  It is difficult for the parents on an infant with fever to know if it is and ear infection or meningitis. 

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

Please stop this bill!!

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

I ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians. W

As an emergency physician in Richmond Virginia I am asking that you stop DUMAS now.  Patients should never be put in the position to determine if they have a life threatening emergency condition before seeking the advice of a medical professional. We ask that you comply with the "prudent layperson" standard and ensures equal access to health care for all Virginians. The drastic cut in medicaid reimbursements by using "preventable" codes will drastically reduce the income for hospital emergency departments which threatens their ability to adequately staff and thereby treat our citizens in a safe manor.  This will disproportionately effect the most vulnerable in our community, including minorities and the uninsured.  

Sincerely,

Cara Marks, MD

How this issue impacts physicians: Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.   Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare.    How this issue impacts patients: Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.     How this impacts health equity: While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because:    Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.   The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.   Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival.    Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.   Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.   How this issue impacts hospitals and health systems: Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes.  Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations.    We ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians.

To the Virginia DMAS Board:

The ER Utilization Program should NOT be implemented, and does not conform to CMS regulations.

 Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.

Patients should never be put in a place where they would need to diagnose themselves prior to coming to the Emergency Department.  Expecting a patient to be able to tell the difference between a benign condition and potentially life threatening condition prior to seeking medical care is dangerous and unethical.  For example; Bell's palsy is very similar to an acute stroke.  Strep throat can be mistaken for a retropharyngeal abscess.  Anal fissures can be mistaken by a layperson for Fournier's gangrene.  These are just a few of the many, many examples why expecting a layperson to diagnose themselves rather than seeking emergent medical care can be dangerous and life threatening.  

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

 Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.

Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare. 

 Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.  

While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because: 

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

 Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes.  Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations. 

We ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians. 

Charles S. Graffeo MD ABEM-UHM

Professor and Asst. Residency Director

Eastern Virginia Medical School

Emergency Physicians of Tidewater

Norfolk, Virginia

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.

• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.

• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 

• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.

• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.

We ask that DMAS temporarily halt implementation July 1st to comply with
the prudent layperson standard and ensure equal access to healthcare for all
Virginians.

The fact is, Emergency Departments are bound by both duty and law (EMTALA) to evaluate and treat any patient who presents to the department for care.  The departments and physicians and administrators cannot control which patients arrive, nor what conditions they arrive with. 

Patients may arrive with chest pain, headaches, abdominal pain, vomiting, etc etc.  Many of these conditions will be benign.  For 99% of headaches, nothing dangerous is going on.  But wouldn't you want the doctor to be willing, able, and available to correctly identify and treat the 1% of headaches that are dangerous (meningitis, subarachnoid hemorrhage, etc)??  Of course you would.  Wouldn't you want the equipment available?  The wait time to be adequately short to be seen in a timely fashion?  Nurses available?  For those resources to be available 24/7, they have to be paid for not just at the rare moment they are needed by a patient with a head bleed, but by all of the other patients who might have needed the resources but turned out not to.

It is completely unfair to all parties (patients and hospitals/EDs) to pay only $15 based on a final diagnosis that is deemed non-emergent.  Patients do not present at the triage desk with heart attacks.  They present with "chest pain" or "nausea", and it is up to astute, reasonably paid doctors to figure out who has a heart attack, and who doesn't.

DMAS policies like this are extremely short-sighted and will cut costs in the wrong way.  A better way would be to spend money on free health clinics where patients can get generic medication refills, health advice, and simple urgent care appointments. 

ED and ED physicians are required by law to treat all patients regardless of insurance status and ability to pay.  ED physicians also believe in in the moral principle underlying our legal obligations under EMTALA: all people deserve care.

• Such dramatically reduced payments will result in fewer physicians in the ER and much longer wait times, specifically in urban and rural hospitals, which have a higher percentage of Medicaid patients.
• The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.
• Underrepresented minorities have always lacked access to healthcare and suffered the worst outcomes in the U.S. This problem was made worse in COVID-19 pandemic. Data from Johns Hopkins University shows that blacks are three times more likely to contract the novel coronavirus and six times more likely to die from it than any other racial group. Emergency physicians are the healthcare safety net when Medicaid recipients do not have adequate access to primary care and public health. These minority groups would be disproportionately impacted and suffer disproportionately when critical-access hospitals lose Medicaid funding essential to their survival. 
• Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.
• Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.