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How Ideas To Cut ER Expenses Could Backfire

Cash-strapped states are coming up with an appealingly simple fix for soaring Medicaid costs: Don't pay for emergency room visits for people who aren't sick enough to be there.

There's a problem, though. It's almost impossible to figure out who's sick enough and who isn't at the moment they walk in the door, researchers say.

"People don't come to the ER with diagnoses, they come to the ER with symptoms," says Maria Raven, an assistant professor of emergency medicine at the University of California, San Francisco. She's the lead author of the study published in the latest JAMA, the Journal of the American Medical Association.

Almost a dozen states have come up with plans to refuse to pay for ER visits or require copays from Medicaid patients if they have a health problem that could have been treated in a doctor's office. They're operating on the widely held premise that people without private health insurance use emergency rooms for minor complaints that would best be treated elsewhere.

To find out if that's true, Raven and colleagues looked at the discharge records for almost 35,000 people who visited emergency rooms in 2009. They identified which people had problems that were "primary care treatable," and then looked back to see what symptoms brought them to the ER.

Just 6 percent of the people had a problem that could have been treated in a doctor's office. But it was impossible to identify them based on symptoms when they walked in the door, because they were the same as those for 89 percent of all emergency room visits. The hundreds of symptoms included toothache, skin rash, abdominal pain, earache, fever and chest pain.

Looking at the people with those symptoms, 11 percent were triaged as needing immediate care, and 12 percent were admitted to the hospital. The three most common diagnoses were abdominal pain, respiratory infection and chest pain.

"If you have a 65-year-old person who wakes up in the middle of the night with chest pain, the only logical thing for him to do it to go to the emergency room," Raven says. "Then the doctor comes in and says, 'Good news, you're not having a heart attack. Maybe you have indigestion.' We certainly don't want people to be discouraged from getting emergency care, especially because in many cases it could be a heart attack."

The idea of identifying "primary-care treatable" cases was not to kick them out of the ER, but to make sure they got good primary care so they didn't have to go to the ER, says Arthur Kellermann, an ER doctor and policy analyst for the Rand Corporation.

"If you're going to apply this logic to reduce support to the emergency department, I suppose we should shut down fire departments because sometimes the public calls with a false alarm," Kellermann told Shots.

"These visits are not happening because people are dumb or lazy or indifferent," Kellermann says. "They're symptoms that primary care is not adequate to meet the acute care needs of the population."

The Affordable Care Act requires that Medicare and private insurers pay for emergency care that a "prudent layperson" would consider necessary. In other words, they can't stick you with the bill if you go in with chest pain and it turns out to be heartburn. But Medicaid patients didn't get the same protection.

In 2011, Washington state said it would stop paying for emergency department visits by Medicaid patients if they were "not necessary for that place of service," but the plan was overturned by the governor.

If similar measures are enacted in other states, hospitals would end up paying the tab for emergency room patients the state refused to cover.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

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