Cutting Medicaid costs through reduced ED visits

Faced with rising Medicaid costs, most states are trying to come up with ways to save money. About a dozen states have proposed plans that would refuse to pay emergency department (ED) costs for patients whose problems could have been solved with a doctor’s office visit, according to the National Association of Healthcare Access Management (NAHAM).

Proponents are basing their proposal on a widely held belief that people without private health insurance use public EDs for minor or routine complaints. The supporters believe that this policy would encourage those individuals to obtain and be treated by a primary care doctor where the care might be better and the price tag is cheaper.

The obvious problem that arises, however, is in figuring out how patients will know what is an emergency, verses what can be treated with an office visit. As an NPR Shots article points out, people come to the ED with symptoms, not diagnoses. Opponents say that enacting a policy such as this one can discourage people from using the ED in cases in which they should be there. Chest pains, for example, can be a heart attack or indigestion, but patients need to be in the ED if it is the former.

Under the Affordable Care Act, Medicare and private insurers are required to pay for ED visits that a “prudent layperson” would consider necessary, such as the chest pains visit that turns out to be indigestion. Medicaid recipients, however, are not afforded the same protection.

One study cited in the article looked at the discharge records for 35,000 people that visited the ED in 2009. When researcher separated out the people who had primary care treatable problems, they were found to only make up 6% of all the records in their study. Additionally, the 6% of primary care treatable patients presented with the same symptoms as 89% of people who went to an ED.

Washington passed a plan to cut ED payments that was overturned by the governor. Without state Medicaid programs paying, the cost for these ED visits would be passed to the hospitals. (To read the entire NPR article, go to