Dear DMAS

It has come to my attention that the Virginia Department of Medical Assistance Services (DMAS) has proposed reducing Medicaid reimbursements for emergency care in cases they have deemed “Preventable” as part of a plan to reduce budgetary costs for healthcare in the State.  The plan involves limiting reimbursements for these cases to Emergency Physicians to $14.98;  about the price of a fast food meal.

At the 30,000-foot level, reducing costs for “preventable problems” sounds like a good thing, right?  I mean, who wants to pay for unnecessary expensive healthcare?  To the unaware taxpayer and politician this all makes sense.  Who is opposed to saving money?

However, when you look at the 17 page list of some 800 emergency medical conditions (Preventable ER visits" code list.  I encourage you to look at the list)  it becomes readily aware that it includes many severe life threatening conditions such as diabetic keto acidosis aka DKA, severe asthma attacks (known as status asthmaticus) and abdominal pain. 

That these conditions are deemed “preventable” is a severe stretch of the meaning to be preventable.  I guess using that definition, almost anything could be preventable. Think about it.   Once you consider this, it becomes obvious that this definition is being used as a veiled way to cut the costs of healthcare by shifting the burden to the physicians and patients under the guise of being “preventable”.  I believe this guise is disingenuous at the least and unethical and immoral at the worst.

To bring you down to the sea-level view, please consider the following:  If one simply Googles DKA management and treatment (or most of the other items on the list) one can see how severe and complicated this condition is and if missed or incorrectly managed, can result in death or other severe outcome.  DKA can be, and often is, triggered by things way beyond a patient’s immediate control. These include such things as severe infections, heart attacks, strokes, etc.  Likewise, asthma is also a complex condition and can be triggered by things beyond the patient’s immediate control and also have poor outcomes, including death, if not managed early or correctly.  Abdominal pain, the third example on the example list is a condition that can be very difficult to diagnose without significant workup.  The causes of abdominal pain are myriad ranging the gamut from minor self-limited causes such as food poisoning and viruses  to other more serious things like mesenteric ischemia, a condition that presents subtly yet if not corrected early can lead to death.  The 17 page list also includes many serious causes in between which can be difficult to rule out yet could be life threatening. Examples of these include appendicitis, pancreatitis, cholecystitis, ectopic pregnancy, to name a few.  I urge you to google any of these conditions and see what I mean.  Having said that when we consider the example of abdominal pain, many times the ultimate cause of this condition is found to be non life-threatening; something that can only be known after doing the compensatory work-up, which takes time for tests, treatment,  medical decision making thoughts and observation not to mention clinical experience.  Making a judgment to reduce reimbursement after the fact (i.e. after all of the prudent leg work has been done to exclude serious causes of the presenting complaint) is unfair and disingenuous.  I say this because:

• Patients do not have the medical knowledge and 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.  
  
  
• Healthcare providers and hospitals should not be used to make up budgetary costs of the state.
  
  
• 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.
  
  
• 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. 

Many politicians and laypersons are not aware that Emergency Physicians/ providers and Emergency Departments in general are required to see all patients presenting to the emergency department regardless of how trivial the complaint or their ability to pay.  This is a federal law known as EMTALA (Google it). 

The level of involvement for a provider to see even the most trivial problem in the emergency department and properly evaluate the problem, document the case in the medical record, explain the problem and treatment plan to the patient not to mention inherent medical-legal risk associated with any patient-provider interaction, greatly exceeds the $14.98  reimbursement (the price of a fast food meal)

DMAS is trying to have it both ways.  The DMAS website home page touts that they are expanding coverage, yet they are drastically reducing payments to those providing the services in the background.  This latter point is not on the website home page, neither is the list of “preventable ER visits” list.

In summary of the above, I believe that instituting the new DMAS reimbursement policy is dangerous to patients, unfair to physicians (emergency physicians in particular) and is unethical.  I urge you to consider the above and halt the July 1^st 2020 implementation of this severely flawed policy and comply with the prudent layperson standard

Sincerely, 

Jeffrey C. Gersbach, M.D.
Emergency Department, Shenandoah Memorial Hospital, Woodstock, Virginia 22664