The state's plan to cut Medicaid would limit visits for potentially serious conditions such as breathing trouble and more.

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Few objected when the state said it needed to prevent Medicaid patients from running up pricey emergency-room bills for such nonemergency conditions as sunburn, acne and diaper rash.

But when doctors, hospitals and parents got wind that the state’s plan also would limit visits for such potentially serious conditions as abdominal pain, breathing trouble and some types of hemorrhage, the proposal unleashed a torrent of criticism.

The plan would cap ER visits to three per year for such so-called nonemergency conditions. As lawmakers and state agencies struggle to close a $5 billion shortfall, this is one of many attempts to pare medical assistance to low-income residents — from adult dental care to support for community clinics.

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The proposal, state officials calculate, could save $72 million to $76 million over two years.

“Everybody knows that emergency-room utilization is way over the top,” said Dr. Jeff Thompson, medical director for the state Medicaid program. “We simply can’t afford it anymore.”

That may be, but it hasn’t stopped criticism of the state’s list of nonemergency conditions — a 15-page compendium of hundreds of diagnosis codes with terse descriptions.

As they pored over the list, critics say, they were astounded to find conditions such as hypoglycemic coma or asthma attacks weren’t considered to be emergencies. They worry that parents and patients might self-diagnose and make risky, life-threatening choices to stay under the limit — particularly since budget cuts are reducing other options.

“Not taking one’s child for treatment for these conditions would result in a report to Child Protective Services,” said Leo Greenawalt, president of the Washington State Hospital Association.

While the association agrees in principle with reducing unnecessary ER use, he added in a statement, many conditions the state is calling nonemergencies could well be “life-threatening emergencies for infants and young children.”

Two-thirds of the 1.1 million state residents covered by Medicaid are children.

As the budget-cutting process grinds away, taxpayer-supported medical care is being rationed, squeezing groups such as illegal immigrants and the working poor.

With doctors’ offices open limited hours and parents often working odd hours, many are forced to get care at the ER, says Dr. Tony Woodward, emergency-services medical director for Seattle Children’s hospital.

“A lot of those families we see at 3 in the morning came from their second job, or their job ended at midnight, and that’s the only time they can come,” he said.

If the new rules scare parents into staying away, he said, the result could be increases in significant illness and even death.

Ticking through the list, Woodward called many “egregious” inclusions. “I don’t know how they got on a list like that,” he said.

Many are tricky to diagnose, but may need quick treatment in children.

Withholding payment for a diagnosis determined after a workup is “Monday morning quarterbacking” — not what a parent faces with a sick child, Woodward said.

Sam Schaible was about 2 when his parents, tucking him into bed in their Seward Park home, found a lump in his groin.

Their private insurer’s on-call nurse told them to hurry to the ER.

There, they were told quick action, possibly emergency surgery, was needed, or Sam could lose his intestines, and possibly his testicles. A loop of intestine had protruded through a hernia and was losing its blood supply.

It all worked; Sam, now nearly 5, is fine. His parents were billed for Diagnosis Code 55090 — “unilateral inguinal hernia.”

It’s on the nonemergency list — one of the conditions the state might restrict for Medicaid patients.

Sam’s parents had another scary experience, this one with the boy’s little brother Gus, who began coughing and having trouble breathing. He had asthma and croup. Those, too, are on the list.

“It’s scary to think that people might decide, ‘Oh, we can wait,’ ” said Lisa Schaible, their mother. “To think that parents might have to make that choice is just crazy.”

While most outrage over the restrictions centers on children, Medicaid clients who account for the largest share of the bills — and the most trips to the ER for these “nonemergency” conditions — are adults ages 19 to 49, often troubled by mental illness and/or substance abuse, Medicaid’s Thompson says.

One adult patient alone ran up ER bills 122 times last year for nonemergency conditions, noted Gail Kreiger, program’s policy manager for the state Medicaid program.

At this point, though, other than letters to clients outlining the new policy, the state has no plan — and no resources, these officials say — to target high users, even though they are largely the problem.

More charity care?

Then there’s that list.

The professor who developed it says it never was intended to be used to make decisions about individual patients or payments.

John Billings, director of the health policy and management program at New York University’s Wagner School of Public Service, did the original statistical work that generated the list. He said it was meant to help officials find out where patients have trouble accessing primary care and help figure out if particular programs work well.

“We explicitly said it isn’t for case-by-case decision-making, either for payment or triage,” Billings said.

Hospitals and ER doctors, who must evaluate and stabilize all patients, are being punished if the list is used to deny payment, he said.

Hospitals know how this is likely to end up: A Medicaid patient uses the ER for primary care or for a recurrent, untreated problem. On visit No. 4, the state refuses to pay.

So the hospital eats the costs — a “mandated increase in hospital charity care,” Greenawalt said.

Seattle Children’s estimates the rules could cost the hospital $50 million over two years — though what part of that could become a tax write-off isn’t clear.

Medicaid programs everywhere are trying to figure out how to save money, Billings says. What Washington is proposing “is not terribly rational, but I’ve heard of even more irrational things.”

Thompson counters that it’s not as though the state wouldn’t pay for any nonemergency ER visits. People would be allowed three such visits before they’re cut off.

He says the list was only a starting point, and he’s recently modified it after more review.

As a result, Thompson says he’s removing six conditions, including convulsions in children and some codes for asthma. An additional 17 conditions could qualify for an exception.

Medicaid officials say the vast majority of Medicaid patients visit an ER — for any reason — no more than twice a year. Only about 2 percent — mostly adults — visit four or more times.

Some of Karen Smith’s children have been in that 2 percent.

She and her husband, Bruce, residents of Shoreline, have had a lot of children — biological, adopted and fostered, including “medically fragile” kids. Medicaid covers foster children and those adopted later.

As her children were growing up, Smith said, she often couldn’t tell what was an emergency and what could wait.

And she’s a nurse.

“This is scary for me,” Smith said. “I can’t imagine how it’s going to be for parents who have no medical background to decide, ‘Is my child sick enough to go to the emergency room?’ “

Taiana, her first adopted child, was born with sickle-cell anemia — an excluded condition on the list but one that could qualify as an exception.

For sickle-cell crises, including two strokes, Taiana was treated in the ER 21 times by age 2 — often at night.

“You have nowhere else to go,” Smith said. “They need to open up 24-hour walk-in clinics. That’s where they have to find a way to fill in the gap, if they’re going to cut down on the ER visits.”

State sees few options

Thompson is dismayed by the furor. “I think everybody needs to take a big deep breath,” he said.

Many people are misreading the codes, he says. Yes, they describe things such as “hemorrhage” and “convulsions” and “hypoglycemic coma,” but the truly emergent versions of these conditions have different codes — which are not on the list.

Conditions such as sunburn or ingrown toenails are easy calls, but chronic conditions on the list — such as asthma or diabetes — are more complicated.

Patients with those problems should be seen by primary-care providers, Thompson says, not only because care in a doctor’s office is expensive, it’s more effective at avoiding crises.

But whose job is it to ensure Medicaid clients receive the care they need outside the ER?

First, patients must take responsibility, Thompson says. Then, communities must help create a system that works. Finally — perhaps forced by this proposal — hospitals must help patients find primary-care providers.

In reality, the state may have few options. Federal law, in general, prevents demanding patient co-payments. And state Medicaid doesn’t have the staff, Kreiger says, to take those frequent ER users by the hand and connect them with primary-care providers.

With the budget crisis, she said, “We’re forced to look at new ways of doing business.”

Carol M. Ostrom: 206-464-2249


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