Medicaid clients may pay higher copays for inappropriate ED use

While many cost-cutting measures being proposed by states to save money in their Medicaid programs require a waiver, this is not necessarily the case with emergency department copays as states already have some flexibility to do this, notes Joan Alker, co-executive director at the Georgetown Center for Children and Families and a research associate professor at Georgetown University's Health Policy Institute.

"A number of states have proposed higher copays for inappropriate use of the ER," says Ms. Alker, adding that charging a copay is not necessarily the right solution for the problem of inappropriate use of the ED.

There must be other providers who are accessible and convenient, patient education about ED use, and available help lines for patients to contact to cut down on inappropriate use, says Ms. Alker. "The copays need to be combined with these other approaches, I think, to be successful," she says. "States need a more comprehensive policy approach."

Peter Cunningham, PhD, a senior fellow and director of quantitative research at the Center for Studying Health System Change in Washington, DC, points to Florida's Medicaid reform initiative, which includes a $100 charge for a non-urgent ED visit.

"I think there are a lot of potential issues with that," he says. "$100 is not going to be affordable for the vast majority of people on Medicaid. And the main problem is, how do you define a non-urgent visit?"

If a possible life-threatening emergency turns out to be something minor, says Dr. Cunningham, hospitals will "just game the system. They will be aware of this and will be creative in how they code the reason for the visit."

Copays, says Dr. Cunningham, are a "pretty blunt instrument to use to try to get Medicaid enrollees out of the ER."

While it's true that Medicaid enrollees do have very high rates of ED use, says Dr. Cunningham, access to care and defining a non-urgent visit must both be considered. "Are there other places for them to go in the community?" he asks. "A lot of providers won't take Medicaid patients because of low reimbursement."

Medicaid programs aren't likely to save much money or reduce ED use significantly by adding copays, according to Dr. Cunningham, "but to the extent they do, it will probably result in problems with access to care."

Contact Ms. Alker at (202) 784-4075 or jca25@georgetown.edu and Dr. Cunningham at (202) 484-4242 or PCunningham@hschange.org.