I am writing to strongly encourage you to delay or cancel implementation of these changes, which will inappropriately penalize hospitals and physicians for certain emergency room visits and readmissions.  If implemented, these changes will be detrimental to Virginia's patients, physicians, hospitals, and healthcare system as a whole.   

Emergency Room Utilization

Some patients’ emergency room visits may be considered avoidable after the fact, but the emergency departments’ responsibility to treat the population is not. As you know, hospital emergency departments have a federal mandate under EMTALA to treat any person seeking care regardless of their condition. As such, this budget amendment penalizes hospitals and emergency department physicians for fulfilling a legal and moral obligation to treat patients who seek care.

It also actively disregards the "prudent layperson standard" - a critical patient protection embedded in federal law and the State Plan for Medical Assistance.  Under this standard, Medicaid patients are assured that if they feel they are experiencing an emergent or life-threatening illness, they should seek care in an emergency department.  It is important that this standard not be weakened.

DMAS had a nearly identical "PEND" plan several years ago that the Virginia College of Emergency Physicians, MSV, and others successfully worked with DMAS and the General Assembly to have eliminated.  The PEND program was an unfair and potentially dangerous program then, and these changes are equally so.

Medicaid Readmissions

When a patient is discharged from a hospital after receiving care, they become subject to environmental and social determinants outside of the hospital’s oversight. Numerous factors can lead to a patient’s readmission, including the inability to afford medication, lack of access to urgent or primary care, including business hours and geographic proximity, lack of personal supports, a challenging living environment and other issues beyond the purview of hospitals. While hospitals do a tremendous amount to set our patients up for success in their treatment and follow up, hospital readmissions would be more effectively reduced by bolstering outpatient services, holding MCOs accountable for health outcomes, improving community partnerships, and lowering prescription drug costs.

I ask that you consider the significant impacts of these changes on patients and our healthcare system and not proceed with the Emergency Room Utilization changes until you receive communication from the Centers for Medicare and Medicaid Services (CMS) that such action is allowable. I also request that you not proceed with the readmission penalty changes.

Thank you for your consideration,

Jake O'Shea, MD, FACEP