Kentucky Medicaid to penalize patients for unneeded ED visits
In an attempt to reduce overuse of emergency departments (EDs) and cut overall healthcare costs, Kentucky will soon penalize Medicaid patients who visit EDs for care not actually deemed as an emergency.
Starting in July, Medicaid recipients who receive coverage through Medicaid expansion will get penalized between $20 and $75 for visiting an ED for non-emergency care. The state Medicaid program will waive the penalty if the patient contacted an insurance company’s nurse hotline before going to the ED.
The move is part of Kentucky’s larger Medicaid revamp that includes requiring recipients to work to get Medicaid coverage.
Kentucky has seen an uptick in ED visits for Medicaid patients over the past few years. Foundation for a Healthy Kentucky said Medicaid paid for 47% of ED visits in 2015 compared to 30% in 2012. That increase is likely because of Medicaid expansion. Charity and self-pay paid for 6% of ED visits in 2015 compared to 23% in 2012.
At the release of the report, Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said policy changes were needed for Kentuckians to get more preventive care and regular doctor visits. “That’s a much less expensive approach, and it results in much better long-term health than going to the hospital in an emergency,” Chandler said.
Kentucky became the first state to receive a waiver to require able-bodied Medicaid beneficiaries to work to receive Medicaid coverage after the Trump administration's policy that allowed states to test work requirements for program recipients. The waiver also allows Kentucky to cut dental and vision coverage for adults and remove recipients above the poverty level for six months if they don’t pay premiums within 60 days.
Kentucky estimates the plan will reduce its Medicaid population by 100,000 recipients after five years and will save $2.4 billion.
Kentucky’s Medicaid ED plan for people covered through expansion is similar to Anthem’s policy. The payer announced last year that it would no longer pay for unnecessary ED visits in a number of states. It has rolled back the policy slightly, including a number of exceptions earlier this year.
The reason for Anthem’s and Medicaid’s policy change is to limit the number of patients going to EDs. Instead, the payers want patients to get non-emergency care at less expensive locations like primary care physician offices, retail clinics and urgent care centers. They would also rather patients use 24/7 telehealth services than go to an ED.
However, critics say restricting or penalizing patients for going to the ED unless it’s an emergency could result in patients delaying care or not seeing a doctor at all.
Much like its opposition to Anthem’s ED and other cost-cutting policies, the Kentucky Medical Association is concerned what the Medicaid change will mean for doctors and the potential to open them up to lawsuits.
Patrick Padgett, executive vice president of Kentucky Medical Association, told Healthcare Dive on Monday that “in a state with no tort reform, this is another example of the liability system and the health insurance system being at odds. Physicians and ERs have to run tests to rule out most any potential diagnosis to not only treat the patient, but prevent being sued.”
Meanwhile, Atlanta-based Piedmont Hospital and five sister facilities are suing Blue Cross Blue Shield of Georgia and its parent company, Anthem, over the payer’s ED policy and a policy of not paying for imaging in hospitals unless it’s deemed an emergency.
Also, the American College of Emergency Physicians and its Missouri chapter called the policy a “clear violation of the national prudent layperson standard.” That standard requires payers to cover patients based on a patient’s symptoms and not their final diagnosis. ACEP said nearly 2,000 non-urgent diagnoses on Anthem’s list of possibly non-covered symptoms can be life-threatening or lead to further health problems. However, Anthem said that only a small percentage of claims have been denied for unnecessary ED use in other states with the policy.