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

During this time in which we are all working together on the COVID-19 crisis, there are several provisions of the ER Utilization Program which would be very damaging to Virginia’s hospitals and present significant challenges, as we work to keep the communities for which we serve healthy and safe. 

Our first concern is with the provision that would require modification of the definition of readmissions to include cases when patients are readmitted to a hospital for the same or a similar diagnosis within 30 days of discharge.  If the patient is readmitted to the same hospital for a potentially preventable readmission then the payment for such cases will be made at 50 percent of the normal rate, except that a readmission within five days of discharge would be considered a continuation of the same stay and would not be treated as a new case.  This creates quite a challenge because 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, but not limited to the inability to afford medication, a lack of coordination of support services, the lack of access to urgent or primary care and possible fear of seeking care during this pandemic.  Hospital readmissions would be more effectively reduced by bolstering services, improving community partnerships, and lowering prescription drug costs.

Secondly, the provision that directs DMAS to reduce Medicaid reimbursements for avoidable emergency room claims.  If the emergency room claim is identified as a preventable emergency room diagnosis, DMAS will direct the Managed Care Organizations to default to a lower payment level.  This would significantly reduce payments to hospitals and physicians, regardless of the amount of work involved or resources used in treating the patient. Hospital emergency departments and emergency physicians already face operating losses for uncompensated care. Under federal law, hospitals are required to stabilize and treat any patient who seeks care at the emergency department.  Reducing Medicaid reimbursements to the hospitals will worsen hospitals’ operating losses for uncompensated care, without having any impact on the number of patients seeking non-emergency care at the emergency room.

A significant component included in the budget language is the use of 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 see care in an emergency department.  Federal law requires the hospital to provide a medical screening examination. Yet the budget provision would penalize the hospitals by cutting reimbursement if the visit is retroactively determined to be avoidable. 

These leads to another issue of major concern regarding the downcoding of reimbursement based on diagnosis for ED visits for all E/M Level 2,3,4. By way of example, at Sentara, we see very low levels of 1 and 2 ER CPT coded claims.  Thus, a majority are Level 3 and 4. If claims are strictly downgraded, by definition these should be used for only simple, straightforward determinations.  From an implementation standpoint, this will be problematic given the demographics and related complications that often exist within the Medicaid population. Also, this low reimbursement makes full staffing of the hospital ER Department very precarious, especially in our urban areas (such as Norfolk) or our rural areas (such as Halifax).  Our Sentara hospitals in these areas typically have a higher concentration of Medicaid population.

These changes would come during a global health crisis that is expected to place an even greater strain on capacity. Sentara Healthcare has worked diligently to reduce hospital readmissions and inappropriate use of emergency rooms.  We have always been pleased to partner with the Virginia Hospital & Healthcare Association, the Virginia Department of Health and DMAS to ensure Virginians have access to quality, affordable health care, and to address issues like these. 

For the reasons outlined above, we respectfully request that these measures not be implemented.