On behalf of Riverside Health System, I am responding to Public Notice—Intent to Amend the State Plan—Avoidable ER Claims and Hospital Readmissions.

There are significant concerns related to the Emergency Room Utilization (Item 313 #28c) and Medicaid Readmissions (Item 313 #29c) provisions in the adopted state budget. The challenge these measures present to Riverside Health System has only increased in light of the current health care crisis as a result of low volumes and increased expenses to ensure we keep the communities we serve safe and healthy. Accordingly, Riverside Health System opposes both measures.

The amendment related to Emergency Room Utilization (Item 313 #28c) directs the Department of Medical Assistance Services to “allow the pending, reviewing and reducing of fees for avoidable emergency room level two, three and four claims, both physician and facility . . . If the emergency room claim is identified as a preventable emergency room diagnosis, the department shall direct the Managed Care Organizations to default to a payment level one.”

This amendment unfairly penalizes hospitals for fulfilling their legal and moral responsibility to treat patients and is problematic for a number of reasons, including:

• It is inconsistent with the federally mandated EMTALA law requiring hospitals to stabilize and treat any patient who seeks care at the emergency department; and
• It is incompatible with the “prudent layperson standard,” which provides patients the assurance of access to emergency department care should they feel they are experiencing and emergent illness, regardless of the ultimate diagnosis; and
• It ignores the responsibility of Medicaid MCO’s to educate their enrollees regarding non-emergency options, including urgent and primary care; and
• It would result in significantly lower payments to hospitals and physicians totaling approximately $40 million annually in a time of a health care crisis that will place increased strain on emergency department settings as a result of additional activity.

Equally problematic is the amendment related to Medicaid Readmissions (Item 313 #29c). The amendment changes the definition of hospital readmissions, aligning it with current Medicare policy. By doing so, it augments the challenge presented by current Medicare policy for hospitals and health systems, reducing reimbursement rates by half should a patient be readmitted to the hospital after five days, but within 30 days of discharge. The reduction in reimbursement to hospitals totals approximately $15 million annually.

In addition to the significant financial consequences, there are several additional challenges this amendment presents. There are numerous factors beyond the control of a hospital or physician that can lead to a patient readmission after discharge—inability to afford medication, food insecurity, absence of transportation resources, lack of access to urgent or primary care, just to name a few.

The amendment ignores the role of Medicaid MCO’s, who are in a far stronger position than hospitals, to provide information related to options for urgent or primary care and to assist with outpatient treatment plans. We welcome partnership strategies with Medicaid MCO’s to ensure high quality health outcomes, but this cannot be the exclusive responsibility of hospitals, which is how it is currently positioned.

Riverside Health System respectfully requests these measures not be implemented.