Don't tie Medicaid to ER discharge diagnoses: researchers

As Medicaid costs surpass all other expenses in states' budgets, several states are considering legislation or regulations that limit payment for Medicaid enrollee emergency department visits that ultimately don't qualify as emergencies.

But, in a new study published in the Journal of the American Medical Association, University of California at San Francisco researchers found that it's often difficult to immediately determine whether patients are having a medical emergency based on their initial symptoms. The researchers came to that conclusion after analyzing almost 35,000 ED visits recorded in the 2009 National Hospital Ambulatory Medical Care Survey.

“The results call into question reimbursement policies that deny or limit payment based on discharge diagnosis,” the authors wrote. “Attempting to discourage patients from using the ED based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care.”

It was determined that, based on “discharge diagnosis” (the physician's assessment of a patient's condition upon release), only 6.3% of the cases studied could be classified as “primary-care treatable visits,” the researchers reported.

They added that the chief complaints these patients originally presented with were the same complaints as 88.7% of all ED visitors. Also, of those that presented with what were classified as “nonemergency” complaints, 12.5% were admitted to the hospital. Of those, the researchers said, 11.2% went to a critical-care unit and 3.4% went to an operating room.

“The point here is that two patients can come in with the same presenting complaint/reason for a visit—these 'nonemergency' complaints—and one may end up with a diagnosis that is not that serious, but another could end up with a life-threatening condition,” the report's lead author, Dr. Maria Raven, said in an e-mail. “Insurance companies should not treat these patients differently.”

In the report, the researchers concluded that “a complex interplay of community, patient and health system factors influence ED use,” and narrow strategies aimed at reducing use probably will not improve the community's health or reduce its healthcare costs.

In an accompanying editorial, Dr. James Adams, with the emergency medicine department at Northwestern University's Feinberg School of Medicine in Chicago, wrote that the study “indicates that some intuitive, oversimplified, yet enduring beliefs about nonurgent patients in the ED should be abandoned.”

“Attention should be redirected away from penalizing patients, physicians or hospitals when a condition turns out to be minor,” Adams wrote. “Instead, the emphasis should be on integration across sites of care, especially for the most complex and most expensive patients.”