Medicaid cuts on ER use

[Guest guest]

Many of you may already be aware of this but it seems to resonant with the

issue of farmworkers who have been reported to overuse or overly depend on

ERs.

Regards,

[The New York Times]

January 17, 2003

White House Allows Limits on Emergency Coverage

By ROBERT PEAR

[W] ASHINGTON, Jan. 16 - In a reversal, the Bush administration has ruled

that managed care organizations can limit and restrict coverage of emergency

services for poor people on Medicaid.

The new policy, disclosed in a recent letter to state Medicaid directors,

appears to roll back standards established in a 1997 law and in rules issued

by the Clinton administration in January 2001 and by the Bush administration

itself in June 2002.

Under the 1997 law, states can require Medicaid recipients to enroll in

health maintenance organizations or other types of managed care. But certain

safeguards for patients were built into that law. Congress, for example,

stipulated that managed care organizations had to provide coverage for

Medicaid patients in any situation that a " prudent layperson " would regard

as an emergency.

Now the Bush administration has decided that states can place certain limits

on coverage of emergency services " to facilitate more appropriate use of

preventive care and primary care, " the letter said.

Administration officials said today that the new policy was consistent with

President Bush's desire to give states greater flexibility in the operation

of their Medicaid programs.

" Some states felt restricted and constricted by the old policy, " said

A. Vadner, the Missouri Medicaid director, who is also vice chairman

of the National Association of State Medicaid Directors. " In a time of

fiscal stress for states, it's all the more important that we have

discretion to manage programs properly. "

States say they are facing the worst fiscal crisis in more than 50 years and

are desperately looking for ways to control health costs. Many have cut

benefits or restricted eligibility in an effort to hold down Medicaid costs,

which rose 13 percent in the last fiscal year, the biggest increase in a

decade.

But Mann, a Medicaid expert at town University, questioned the

legality of the new policy.

Senator Bob Graham, Democrat of Florida, a principal author of the 1997 law,

said the new policy " would undermine access to essential emergency services

for low-income Americans, " including children, the elderly and the disabled.

Mr. Graham said he did not understand how the administration could, by a

letter, make such profound changes in a policy established by statute.

Administration officials said the basic Medicaid law allowed states to set

reasonable limits on the amount, duration and scope of services.

The letter was sent to state officials by Dennis G. , the Bush

administration official in charge of Medicaid. Under the old policy, Mr.

said, states could not limit coverage of emergency services for

Medicaid beneficiaries in managed care. " When the prudent layperson standard

is met, " the old policy said, " no restriction may be placed on access to

emergency care. Limits on the number of visits are not allowed. "

More than 40 million people are insured through Medicaid. More than 55

percent of them are in some type of managed care.

The letter does not specifically say what kind of limits can be imposed, but

state officials have discussed ideas like limits on the number of emergency

room visits that would be covered.

Ben A. Bearden, the Medicaid director in Louisiana, said his state wanted to

limit Medicaid coverage for adults to three emergency room visits a year.

" Three emergency visits a year for an adult may sound like a small number,

but it's really not, " Mr. Bearden said today in an interview. " I'm 60 years

old, and I've been to an emergency room once in my life. The E.R. is very

expensive, and people in this state use it inappropriately. They go in for a

stubbed toe. "

Louisiana used to have a three-visit limit, Mr. Bearden said, but, at the

insistence of federal Medicaid officials, the state ended the restriction

for people in managed care a couple of years ago.

Under one form of managed care, states pay primary care doctors to

coordinate care for Medicaid recipients.

Mark D. Trail, the Medicaid director in Georgia, said that prior to 1997,

his state required an emergency room to get authorization from the primary

care doctor before treating a Medicaid patient enrolled in the state's

managed care plan.

Georgia did away with that requirement because of the 1997 law. " Since

then, " Mr. Trail said, " use of hospital emergency rooms has spiked, " and the

state is seeking ways to reduce inappropriate use.

Mr. Vadner, the Missouri official, said states recognized their obligation

to cover emergency care. But there is often a dispute over who should pay

and what services are needed.

Mickey, a policy analyst at the National Association of State

Medicaid Directors, said state officials had sought a clarification of

federal policy on emergency care. The new policy, she said, is " above and

beyond what the states ever requested or expected. "

Senator Graham introduced a bill to establish the " prudent layperson "

standard for all insurers in 1997. The standard was included in the Balanced

Budget Act of 1997, as a requirement for managed care plans serving people

in Medicaid or Medicare. The purpose, Mr. Graham said, is " to allow a person

who reasonably believes that he or she is undergoing an emergency condition

to be evaluated, treated and stabilized in the emergency room without fear

that the health plan will later deny the claim. "

A prudent layperson is defined in the law as a person with " an average

knowledge of health and medicine. "

Doctors and hospitals said the prudent layperson standard was needed because

H.M.O.'s had often refused to pay for emergency care after concluding that

there was no real emergency - if, for example, chest pains resulted from

severe indigestion rather than a heart attack.

Under the law, the managed care plan is supposed to pay for the emergency

care, regardless of whether the patient got " prior authorization. " The

patient can go to the nearest hospital, regardless of whether it is in the

health plan's network of providers.

The Bush administration issued rules interpreting the law on June 14, 2002.

In a news release at the time, the administration said, " Health plans must

pay for a Medicaid beneficiary's emergency room care whenever and wherever

the need arises. "

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