By Dr. Todd A. Parker
Imagine your house is on fire.
You call 911, the fire department responds, puts the fire out, and saves your house. Now imagine the government decides they want to spend less on fire department costs, so they create a list of “preventable causes of fires,” like an electrical short from an old appliance, or a fire in a chimney that wasn’t cleaned out. Then, anytime that the fire department responds to a fire caused by one of these “preventable” causes, they cut the pay of the fireman by 80%, hoping somehow the firemen will prevent the fires.
Does this make sense? Of course not.
Firefighters are part of society’s safety net, and emergency departments are the safety net of the healthcare system. We not only provide the majority of unplanned and emergency care, but we also care for the most vulnerable in our society. We treat patients regardless of race, sex, background, or insurance. The uncertainties of the job — ready 24/7 to take whatever comes in — keep it exciting.
One thing is certain, however: Whether you practice emergency medicine in the inner city or the farmlands, you treat low-income Medicaid patients daily. For many patients, emergency providers are the only ones who will care for them.
So, imagine our dismay when Virginia’s legislators and the governor signed a budget amendment, effective July 1, that is the medical equivalent of the fireman scenario above. To reduce “preventable emergency department visits” and save money, Virginia created a list of 790 diagnoses for which an ER visit is considered “preventable” with proper primary care.
Medicaid payments for these 790 conditions — many health emergencies we see every day — now pay less than $15 per visit. These are conditions such as acute abdominal pain, diabetes complications, breathing issues in pregnant women, even severe asthma. Like firefighters cannot prevent fires, emergency physicians can’t stop emergencies. We’re there to take care of it when it happens.
Further, emergency departments, via a federal law called the Emergency Medicine Treatment and Labor Act (EMTALA), are required to treat all patients regardless of insurance status or ability to pay. Emergency physicians don’t care and cannot ask about insurance, and we believe in this 1986 law’s principle: All people deserve care regardless of ability to pay. For those who don’t have access to primary care and public health resources — often already the most vulnerable populations — we may be all they have.
There is precedent for Virginia that should be heeded. When a similar policy was enacted in Kansas in 2017, the Centers for Medicare and Medicaid Services (CMS) disallowed the program, stating, “we prohibit the use of codes (either symptoms or final diagnosis) for denying claims” and “the final determination of coverage and payment must be made taking into account the presenting symptoms rather than the final diagnosis.”
CMS obligates state Medicaid programs and managed care organizations to adequately reimburse doctors and hospitals for emergency medical care based on presenting symptoms, not a diagnosis list. That Virginia believes they can treat Medicaid patients differently than every other state is concerning and illegal.
Virginia’s issue is exacerbated by louder calls for greater social justice and racial equity in healthcare. As our Commonwealth and nation consider the broader issues of social equity and dismantling structural racism, it is important to recognize that Medicaid patients are disproportionately people of color. Many have chronic conditions requiring ongoing treatment, and when primary care doctors won’t see them and public health infrastructure is lacking, the emergency room is where they turn.
This budget action creates two standards of care in Virginia – one for commercially insured, and one for Medicaid patients, which sends the message that one group is inferior to the others.
Underrepresented minorities have always lacked equal access to healthcare and suffer the worst health outcomes in the U.S. Racism is a social determinant of health and a true public health emergency, and emergency physicians view our responsibility as promoting health equity within the communities we serve.
And the issue is made worse by COVID-19. Blacks are three times more likely to contract COVID-19, and six times more likely to die from it than any other racial group. Twenty-six percent of deaths are in the Latino community. Should Virginia’s program be allowed to continue, minorities will be disproportionately impacted when critical-access hospitals lose Medicaid funding essential to their survival.
I work in a critical-access hospital in Onancock, on the Eastern Shore – the governor’s hometown. It serves one of the highest percentages of Medicaid patients in Virginia. This proposal will gut our hospital — the only one within a 120 mile stretch of one of the most disadvantaged parts of Virginia. Many of our poorest citizens will suffer, and people of color will suffer even more.
Virginia’s actions will cripple Emergency department’s ability to provide quality access to care. As an emergency physician, I can tell you that now is the time to seek equity in health care, not reduce it. We must end health care disparities, and treat all Virginians equally, with respect and with open arms.
Dr. Todd A. Parker is the medical director at Riverside Patient Transfer Center and secretary/treasurer of the Virginia College of Emergency Physicians.
Editor’s note: On Monday, the Virginia College of Emergency Physicians and other organizations sued the Virginia Department of Medical Assistance Services seeking to halt cuts in reimbursements for certain emergency services.