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States consider penalizing non-emergency ER visits

March 19, 2013 12:00:00 AM PDT
Some states are proposing Medicaid payments be denied when people go to the emergency room but end up being diagnosed with a non-emergency condition. A new study points out why that may be flawed.

If you go to an emergency room, you can usually expect a long wait. Many people go to E.R.s because they don't have primary doctors. But since emergency departments cost hospitals millions of dollars to operate, many are looking for ways to cut costs.

It happens all the time: A patient arrives at an emergency room with chest pains or other frightening symptoms.

"It could be a life-threatening diagnosis or it could be something that ends up not being an emergency," said Dr. Maria Raven, UC San Francisco.

Chest pains could indicate a heart attack, but it could also result from a less-severe condition such as gastritis or heartburn.

To keep costs down, some states are considering a deterrent for patients: If they leave the hospital with a diagnosis that turns out to be a non-emergency, their insurance provider may not pay for the entire E.R. visit.

"That would potentially threaten patients' ability to access emergency department care because they might be afraid to come in if they feel their visit isn't going to be paid for," said Dr. Raven.

UC San Francisco researchers evaluated nearly 35,000 emergency department visits. The goal was to determine how often patients with the same symptoms turn out not to be emergencies.

The results are provided in a report from the Journal of the American Medical Association.

"The vast majority had abnormal vital signs. Many arrived by ambulance. A substantial portion needed to go to the operating room from the emergency department," said Dr. Raven.

So researchers used a formula popular with policy makers. The result: 6 percent of E.R. patients released from the hospital had a diagnosis that could have been treated by a primary care doctor.

But their symptoms may have pointed to something serious. And a majority of all patients who came to the E.R. had similar complaints.

Researchers say if a nurse were turn away someone with those symptoms, more than 90 percent would have a condition that needed immediate attention.

"Policies to discourage use of this needed resource for a lot of people, especially Medicaid patients who often don't have the same access to other care and who are some of the people who are most vulnerable to these policies, is not good policy," said Dr. Raven.

The bottom line: It's not reasonable to expect a person to figure out if they're having a real emergency or not until they're actually in the E.R.

One expert not involved in the study says the biggest costs lie with frequent visitors to the E.R., who add up to about one-quarter of all E.R. visits.


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