The emergency room is the medical safety net for people in communities across our commonwealth. Ensuring the ER’s viability is not only a financial issue – it is a moral one that impacts our community’s equity, access, and safety. 

Equity and Access. The ER is used by patients of all socioeconomic classes, but a disproportionate majority of ER patients are from lower socioeconomic classes.[1] The majority (62%) of U.S. ED visits for patients under 18 years of age have a primary payer of Medicaid and this proportion has steadily increased over time.[2]  Non-white people make up over 59% of Virginia’s Medicaid population but encompass only 32% of Virginia’s population (2018 US Census ACD 5-year survey).[3]^,[4] African Americans have worse clinical outcomes for almost every disease process which we treat in the ER, and recent reports of increasing COVID-19 incidence and morbidity in African Americans visibly display how yet another critical disease is hitting this community hardest.[5]^,[6] In our current pandemic, most children that I care for as a physician who present to the ER with COVID-19 symptoms are not critically ill and might have a final diagnosis of an upper respiratory tract infection with fever; under the proposed 12-VAC 30-80 Reimbursement Changes Affecting Other Types of Care, most of these patients would likely be billed as an “avoidable emergency room claim” – however, many of these children will require extensive diagnostic workups, recommended by the Centers for Disease Control (CDC), to ensure that they do not have early heart failure and fatal septic shock that has been well described in the newly described Multisystem Inflammatory Syndrome in children (MIS-C).[7] Defunding ER care has contributed to widespread closures of ERs across the state and country, despite increasing numbers of people seeking care in the ER.[8] Closure of ER have been associated with increased mortality of patients in the surrounding areas, a critical access issue given that ERs average 43 visits each year for every 100 people.[9]^,[10] Targeting the reduction of compensation for ER patient care threatens the viability of a medical safety net setting that disproportionately serves to ensure the health of non-white populations – this would be a blight to our pursuit for a more just and equitable society for all Virginia residents.

Safety. In order to stand ready to respond with life-saving capacity to safely manage trauma, for times such as the 69-car pileup accident on I-64 in the early Sunday morning hours of December 22^nd last year,[11] large multidisciplinary trauma teams need to stand at the ready in regions all over our state. ER staff cannot flex down below certain quality assurance minimum levels, such as when patient ED volumes decreased by over 60% during the COVID-19 epidemic in April of this year, as can be done in other clinical practice settings.  We stand ready, fully staffed, to serve Virginians who are sick or acutely injured.  We do so gladly, even with the increased risk to our own personal health, as has been seen nationwide and in Virginia, with physical attacks to our team by the ever-rising tide of mental health patients, as well as the infectious risks that ER staff have faced  in caring for COVID-19 patients on the frontline. When pandemics like H1N1 influenza (2009) and the current COVID-19 happen – the ER is keeping Virginia safe. When increasing numbers of people are in crisis with life-threatening mental health or substance use disorders – the ER is ready to stabilize and coordinate the safe care that they need. Defunding the ER is a threat to the safety of all Virginians.  

We strongly oppose the “Reimbursement Changes Affecting Other Types of Care (12VAC 30-80)” because it is a threat to all Virginians from an equity, access, and safety standpoint. 

Sincerely,
The Pediatric Emergency Medicine Physicians & Nurse Practitioners at the Children’s Hospital of the King’s Daughters