Medicaid proposes reimbursement change for ERs

Too many people are going to expensive emergency rooms for care that should be provided in a doctor’s office, statistics show.

The state recognizes that people are still going to emergency rooms needlessly and often those bills are going to state taxpayers. DHH is hoping to institute a program that would motivate hospitals to make an immediate assessment, then refer the patient elsewhere.

Hospitals are balking at the idea, saying they fear such a system could increase the possibility of mistakes.

The state Department of Health and Hospitals Secretary Kathy Kliebert is proposing new Medicaid reimbursement policies aimed at changing patient and medical provider behaviors. Kliebert calls the initiatives “payment reforms.”

In translation, it means cuts in hospital and physician reimbursement for care of those covered through government insurance for the poor.

Kliebert said hospitals would be reimbursed a flat $50 fee to assess and refer to doctor’s offices those patients who show up at their doors who do not have an emergency medical condition. A $4.5 million annual savings is projected. The agency has published a notice of its intent to implement what it calls a “triage fee.”

The planned change impacting emergency room treatment isn’t sitting well with the Louisiana Hospital Association.

“It’s an additional cut, and obviously, we are going to be strongly opposed,” said Sean Prados, the Hospital Association’s vice president. “While it’s well-intended to try to keep nonemergency patients out of the emergency room, it’s a misguided approach because they will not change behavior.”

Prados said many emergency room services are provided to people who earn hourly wages and go to emergency rooms after hours or over the weekend when they are not working.

Kliebert said the idea is to identify those people who don’t need emergency room care and refer them to a physician. The idea is to encourage people to build a relationship with a physician on whom they can rely for ongoing care.

She said the $50 fee is “a reasonable rate” if a patient is seen, not by an emergency room doctor, but by a nurse who does the screening.

But Prados said hospitals are not likely going to take the chance that symptoms that appear minor aren’t signs of a bigger medical problem.

“When someone comes in with a chest pain or a bump on the head, they will have to eat the costs of the battery of tests the patient has to go through while they try to determine whether it’s life-threatening,” Prados said.

Kliebert said the health agency is aware of hospitals’ concerns and has been in discussions about potential alternatives.

She said private health plans that now provide care for two-thirds of the state’s 1.2 million Medicaid enrollees are interested in diverting people away from emergency rooms.

Reductions in emergency room use is one of the yardsticks by which the success of managed care plans is measured. The lower reimbursement proposed also helps the plans’ financial bottom line.

Kliebert said reductions occurred in other states that have adopted a “triage” fee .

“The plans have offered to put people in emergency rooms and are willing to work with the hospitals,” she said.

A birth initiative comes on the heels of a major push — endorsed by the Louisiana Hospital Association — to stop medically unnecessary births prior to 39 weeks. Louisiana ranks poorly in national ratings on premature births.

Kliebert said the voluntary push has been successful “but there are still some doctors out there who say there are not going to be forced to do it.” An estimated 250 Medicaid babies are born prior to 39 weeks.

Now there will be a financial disincentive to force the issue, she said.

The idea is to reduce the number of babies born with low birth weights, the number of days babies are in neonatal intensive care units and the number of unnecessary cesarean section as well as to prevent complications for new mothers and newborns.