RE:  Comments regarding policy to reduce Medicaid reimbursement for ER care if visit is retrospectively determined to be preventable.

I strongly agree with Virginia American College of Emergency Physician’s comments provided on this topic and encourage policy makers to pay close attention to how this policy will negatively impact health equity.  The following are my personal comments.

Determining that an ER visit was preventable after it has occurred involves many subjective layers and is problematic.  Is an ER visit preventable if the patient is referred by another medical professional, nurse hotline, or internet search aide?  The Prudent Layperson standard protects individuals from being expected to self-diagnose symptoms.  All of us practicing emergency medicine have seen patients who signed in with abdominal pain or dental pain and end up actually having heart attacks.  I have read that diabetic ketoacidosis and status asthmaticus are on the list of diagnoses that could be determined to be related to avoidable ER visits.  This is simply absurd.  Many patients with diabetic ketoacidosis require intensive care admissions and status asthmaticus is a state of persistent respiratory distress related to underlying hospitalization often requiring hospitalization for stabilization. 

Emergency departments take their EMTALA obligation seriously and this has created a culture of do what is best of the patient regardless of ability to pay and thus the prudent layperson standard helps protect everyone’s access to high quality emergency medicine care regardless of how and if a patient is insured.

Emergency departments serve the most vulnerable populations 24 hours a day, 7 days a week regardless of holidays, weekends, and pandemics.  There is significant financial cost to have an adequate state of readiness and efforts to cut costs affecting critical infrastructure will result in unintended consequences adversely affecting many people.   I highly encourage government programs to think next level and figure out ways to financially support and protect the decision making of the most capable triage resource in our healthcare system, the emergency medicine physician.

Dennis Bernier, DO, MBA, MPH, FACEP

Leesburg, Virginia