HD33 - Emergency Room Use By Virginia's Fee-For-Service Medicaid Recipients


Executive Summary:
In 2004, the General Assembly adopted language in the Appropriations Act -- Item 322 G -- directing the Department of Medical Assistance Services (DMAS) to study the degree to which hospital emergency rooms are being used by Medicaid fee-for-service (FFS) recipients for non-emergency care.

Because of 24-hour access policies and federal law that requires emergency rooms (ER) to treat and stabilize patients who present for treatment regardless of ability to pay, there has been a long-standing concern that ERs are being used as primary care clinics. Studies of this issue have concluded that anywhere from seven to 55 percent of all visits to ERs are for non-emergencies.

The results from DMAS’ study, which focuses on Medicaid recipients who are not in a managed care program, found that in 2004, nearly 35 percent all Medicaid ER claims appeared to be for non-emergency care (see figure on numbered page "i."). Other factors being equal, Medicaid recipients who are more likely to use the ER for non-emergent care are females, legal citizens, infants, and young adults.

Still, it is important to note that the rate at which Medicaid recipients use the ER for routine care has declined by 15 percent since 2002 when it reached as high as 40 percent. This decrease might reflect the increased efforts of hospitals such as the Virginia Commonwealth University Health System that use outreach strategies to reduce the number of patients who use the ER as a substitute for a primary care physician.

Because of federal restrictions, State Medicaid agencies cannot require hospitals to immediately divert from the ER, those Medicaid patients who seek routine care on an emergency basis. Further, without a review of the claims, Medicaid staff cannot automatically reduce payments for the non-emergency care that was provided in the ER. Due in part to these restrictions, only ten of the 32 States surveyed for this study have established policies that are designed to discourage Medicaid recipients from using the ER for non-emergent care.

DMAS presently operates a program that is designed to discourage the inappropriate use of the ER. Recipients who use the ER in this way are subject to be enrolled in the agency’s Client Medical Management program. Recipients targeted by this program are assigned a case manager and receive materials that educate them on the appropriate use of the ER. However, resource limitations have greatly restricted the scope of the program, which presently serves less than three percent of those who use the ER for non-emergent care. If this program is to be expanded, more staff resources will be needed.