To: DMAS

Re: Emergency Department Utilization Program

I am a recently retired emergency physician. We in emergency medicine have been explaining for years the folly in retroactively denying payment for services that appear to be non-emergent. This on the surface may appear reasonable only if one ignores the plight of the patient and family having to determine what is emergent before entering the emergency department. Retroactive withdrawal of payment based on final diagnoses is clearly flawed and has been tried before. A better judgment of an “appropriate” visit is to examine the Evaluation and Management code of the provider for the visit. That benign cough could be Covid pneumonia in a well-looking patient who has an unexpected critically low oxygen level. You can’t diagnose this without expensive testing and having trained personnel available around the clock.

I have reviewed the list of “preventable ER visit” diagnoses. In many cases I recognized many that could not be distinguished from truly emergent diagnoses without expert evaluation and testing.

Examples of the shortcomings of the retroactive denial include streptococcal pharyngitis (bacterial throat infection) that may appear non-emergent but cannot be differentiated by a lay person from an acute epiglottis (clearly emergent and life threatening) or a peritonsillar abscess (also urgent to emergent, depending on severity) which may require an expensive CT scan and trained specialists to be available at all times. Another example is abdominal pain which could be caused by an inferior wall heart attack which can be indistinguishable from simple acid reflux based on history, or ear pain may be simple swimmer’s ear or it could be malignant otitis externa (an emergent condition). Abdominal pain could be from a mild viral infection, or it could be from an infected kidney stone (emergent), perforated or twisted bowel (emergent) or a whole host of problems that I could expand upon. The elderly and the young may present looking well and then rapidly deteriorate. Ask any qualified emergency physician with experience and they will regale you with cases that appeared benign and ended up much worse. Unless you are medically trained you wouldn’t know how to differentiate these problems and the poor lay person cannot be expected to either. To penalize the patient and the doctor who has to examine, treat and diagnose the problems, often with expensive testing is unfair and, really, immoral. Insurance companies had been using this retrospective analysis until the “prudent layperson” standard was agreed upon and this should remain the criteria for medical necessity.

Emergency departments must be staffed and equipped for the most severe cases and disasters around the clock. We have to evaluate every patient who walks or is wheeled or carried into the department 24 hours a day and regardless of ability to pay. This is expensive.

To cut costs, the State CAN set up a telephone triage that has been vetted by emergency and other specialists with a robust quality review and also have alternative sites AVAILABLE for the non-emergent cases. The triage system can also coordinate with case managers who can track the very expensive “frequent flyers” who abuse and clog up the emergency department (ED) and they could also give the ED a heads up when they send a patient in to be evaluated and, in a patient with a predominately pain complaint, look up their utilization on the states’ controlled substance lists. The actual cost of an incremental non-urgent patient is very small (personnel, utilities are already there) and the cost can be adjusted if the patient was accurately screened prior to arrival. Consider the toothache or ear ache. If you ever had these either of these problems you will know that the pain can be agonizing and to wait to see someone the next day (if they take your insurance and have an opening) is suboptimal. If the triage nurse can suspect a non-emergent diagnosis they can send the patient in to the ED to rule out a more serious cause or, in a closed medical system, even consult with a prescriber to order medication.

Emergency medicine is highly stressful and I am proud of my specialty which has stepped to the forefront of all types of disasters including Hurricane Katrina and the present pandemic. Not everyone can do this job well. We have to cover 24 hours a day and be ready for anything. This takes a heavy psychological, physical and longevity toll on the provider and his or her family. I was a medical director of a busy emergency department and good emergency doctors are a precious commodity. We have a shortage of doctors which is certainly not going to improve if we ratchet down fees retroactively and unjustifiably.

We are the providers of last resort in our medical system. We are the safety net. We see the sickest and poorest patients with multiple social and medical problems. Many of the diagnoses on the “preventable” diagnosis list.  We will see these patients without complaint but we must not be compelled to work without reasonable remuneration.

Please halt the implementation of this "preventable" list and please comply with the prudent layperson standard. We must strive to ensure equal access to healthcare for everyone.