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Saturday, January 18, 2003"It seems too weird . . . to say to a kid with asthma, you can only stop breathing three times a year," But is that what they’ve said? In the four-paragraph letter to the states first reported by the New York Times, Dennis G. Smith, Medicaid director at the Centers for Medicare and Medicaid Services (CMS), wrote that the agency previously had told states that they may not limit Medicaid patients' emergency room visits and must pay for all days those patients remained in the hospital following emergency care. "This letter is to inform you that [the agency] is removing both of these requirements," Smith wrote. That’s not quite the same as telling someone they can only have an emergency so many times a year. That’s just telling them they can't expect the state to pay for every treatment sought through an emergency room. As many a busy ER doctor will tell you, not every treatment sought in an ER is an emergency. That’s why you sometimes have to wait seven or eight hours for treatment. But what about that bit about limiting the reimbursement for hospitalization? You would think that if someone needed hospitalization, then it was a legitimate emergency. Well, unfortunately not always. Sometimes people are admitted for "social reasons" - i.e. their family just doesn't want to deal with them anymore. Sometimes no medical ailment can be found but they insist that they're too sick to go home. With private insurance, unnecessary admissions like that can be avoided by pointing out to the patient and their families that they'll be responsible for the hospital charges. That doesn't fly with Medicaid patients, because Medicaid covers everything. Consider the case of Medicaid managed care, those programs that were touted in the 1990's as the solution to runaway costs. Previous rules said that Medicaid programs had to pay for ER services that any “prudent lay person” would acknowledge as justifiable. The problem is defining what a “prudent lay person” thinks. That has been difficult for Medicaid managed care companies to determine, so they end up paying for everything, then opting out of the Medicaid business, or worse, going bankrupt. I remember when Ohio began forcing Medicaid patients into managed care plans about six years ago. One of the managed care plans that our office accepted decided to give it a go, and it was a disaster. They stayed in it for about two years. They were admirably committed to access. Not only was I expected to do my usual duties - providing medical care, being available in the night for emergencies - but I was to call a cab for patients if they needed to go to the ER in the middle of the night. (The fare was paid by the managed care company.) The problem came in sorting out the emergencies from the non-emergencies. There were definitely a lot more calls in the middle of the night from the Medicaid patients. Calls for things like “I want to be checked out for VD” or “I think I have a yeast infection,” or “My child has had a runny nose all week.” Most of those calls quickly became adversarial when I tried my usual line of questioning about the symptoms to decide if it could wait for an office visit in the morning, or if they really indeed had an emergency and just weren’t expressing it as such. It was obvious that the callers’ one goal was to get authorization to go the ER, not medical advice, and my questions were seen as obstructions to that goal. (You see, it’s so much easier to go get care right now, when you’re thinking about it, you’re awake, and you’re not doing anything else at the moment. It’s quite another thing to call the office, make an appointment and to show up on time.) If I refused to authorize a visit, I usually got a call from the patient advocate at the managed care company the next morning, demanding an explanation. After a while, I gave up. I authorized everything. So did my partners. We still have Medicaid managed care here, but I don’t get those types of phone calls as much. That’s because the managed care companies have given up, too. They no longer require authorization for ER visits. Now, I just get ER reports documenting treatments for yeast infections and runny noses. I also get nagging letters from the managed care companies pointing out the ER abusers who have signed up with me. I want to know, how am I to change their behavior when none of them have once bothered to call the office or to stop by to set up an appointment? One thing for sure, if Medicaid is to remain solvent, they have to set some sort of limits. posted by Sydney on 1/18/2003 08:18:00 AM 0 comments 0 Comments: |
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