Commenter:
Lewis Siegel, Chesapeake Emergency Physicians
Stop the DMAS ER utilization program
I am writing as an Emergency Physician, to ask that the plans to implement the ER utilization program scheduled to begin July 1st, 2020 be halted for the reasons included below as well as the numerous emails and messages that you have already received. I have included talking points below. As an Emergency Physician in Virginia for the past 27 years, I have seen many issues come before us that have threatened, to some degree, the ability for us to maintain the staffing, quality, ability to recruit to be able to best take care of all patients that present to the Emergency Department that believe they have an emergency condition that needs to be addressed. This issue, is an old one, that had been addressed on various occasions in the past, initially with level 4's and 5's in the 2000's and with the level 3's in 2015 when Governor Northam supported ending the PEND program after 15 years of efforts by Emergency Physicians in the state. The program that is currently slated to begin July 1st reverses all of the progress that we had made on this issue and would paralyze Emergency Physicians and their departments from being able to adequately care for all patients who need our care and present to the Emergency Department. EMTALA mandates that all patients receive a medical screening exam when they present to the Emergency Department, a federally mandated program but also an ethical responsibility that we feel as Emergency Physicians to provide care to all patients, regardless of ability to pay, when they come through our doors. Prudent Layperson laws also are crucial to understand with this issue as to previous legislation that requires care be provided if a patient believes that they may have an emergency condition. We cannot expect patients to be able to determine whether chest pain, abdominal pain, headaches or cough and breathing difficulty, are emergency conditions that need to be evaluated immediately in an Emergency Department or in an outpatient setting. To put patients in this position will absolutely lead to delayed care of emergency conditions, complications and deaths.
The timing of such a program when our state's emergency departments are doing everything they can to care for all of our patients, while the pandemic is ongoing and will be for an unknown period of time. We are taking risks of a higher level than every emergency physician and providers have known in their careers while wearing PPE constantly in the Emergency Department. This program would paralyze our ability to care for patients, during the pandemic, and going forward, because it would lead to gutting of staffing due to financial consequences and inability to recruit further providers. Many of the patients that are presenting on a daily basis to our Emergency Department with fear of having COVID and fear that they may die from this potentially fatal disease, are patients that would end up with a diagnosis included on the "preventable" list. This program would paralyze the front-line from being able to maintain our staffing. Hospitals would be paralyzed as well and many would not be able to survive the dire financial blow of such a program and would be forced to close. This will further stress and incapacitate our health care safety net that emergency departments provide. I have included talking points below. On behalf of Chesapeake Emergency Physicians and all emergency providers statewide, please halt the implementation of this program so Emergency Departments can continue to provide emergency care to every patient that presents with what they believe may be an emergency condition, and so that we as emergency providers, can safely and most effectively, provide the care that is federally mandated by EMTALA laws for these same patients.
Sincerely,
Lewis Siegel, MD
Chair, Department of Emergency Medicine, Chesapeake Regional Medical Center
Medical Director, Chesapeake Regional Medical Center Emergency Department
Chesapeake, Virginia
Talking Points:
How this issue impacts physicians: Emergency departments, by federal law (EMTALA, or the Emergency Medical Treatment and Labor Act), must treat all patients regardless of insurance status ability to pay. Emergency physicians also believe in this decades old law’s moral principle: All people deserve care.
Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care — both during the current COVID-19 crisis and long after. This issue is also exacerbated by louder calls for greater social justice and racial equality in healthcare.
How this issue impacts patients: Patients 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.
How this impacts health equity:
While Medicaid patients will continue to receive care and will never be billed for the difference if the visit is determined to be non-emergent, patients will be impacted because:
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.
The financial viability of these emergency departments and medical centers is already threatened due to losses from COVID-19 where, during lockdowns, volumes declined as much as 40% due to both a lack of vehicle traffic and patients delaying care and avoiding emergency rooms.
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.
Minorities in the U.S. disproportionately have higher rates of co-morbidities that increase risk factors for COVID-19 (obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases). Many of those conditions are on the “preventable” diagnosis list.
Emergency physicians are dedicated to our national mission to promote and strive toward health equity within the communities we serve. Allowing such an unfair policy to go into effect in Virginia would be a significant step backward towards racial equality and social equity.
How this issue impacts hospitals and health systems: Medicaid reimbursements would be automatically cut to only $14.98 if an ER visit is on the list of “preventable” codes. Such a low reimbursement makes full staffing of a hospital emergency department very precarious, especially in urban and rural areas who typically have high Medicaid populations.
We ask that DMAS temporarily halt implementation July 1st to comply with the prudent layperson standard and ensure equal access to healthcare for all Virginians.
