Hospital emergency rooms are the place to go with a medical emergency — an acute condition that requires immediate and possibly specialized treatment.
Providing such care is expensive and an emergency department’s capacity is limited, so it’s wasteful to use such a facility for routine, non-acute health complaints.
A new law, signed by Gov. Phil Murphy last month, should help discourage the inappropriate use of emergency rooms by managed-care Medicaid recipients and reduce the program’s cost to the state.
The law caps reimbursement for ER visits for such patients at $140 when they seek treatment for low-acuity complaints such as a minor cut or fever that would be better and more cost-effectively treated by a primary care doctor. The N.J. Association of Health Plans says the average cost of such visits has been $600. The state will publish a list of medical conditions considered non-emergency under the law.
The federal Agency for Healthcare Research and Quality says an estimated 13 to 27 percent of emergency department visits could be managed in a physician office, clinic or urgent care center, saving about $4.4 billion annually nationwide.
The National Center for Health Statistics says Medicaid beneficiaries use hospital emergency rooms at nearly twice the rate of those with private insurance.
The legislative sponsors of the new law said Medicaid recipients are sometimes going to emergency rooms because they can’t get the appointment they want with their primary care provider or haven’t even selected a primary care provider.
The New Jersey Hospital Association says the Medicaid patients are showing up in emergency rooms because managed care organizations have failed to provide proper access to care.
But they’re also showing up because it’s convenient, and some hospitals encourage such inappropriate use.
One New Jersey hospital’s website tells visitors they can be treated for their “sore throats, fever, cold symptoms and minor lacerations” in its emergency room. Another says it is ready to treat sprains and insect bites there.
Legislators are also proposing increased oversight and better management tools for Medicaid’s non-emergency transportation network. The system of private drivers and shuttles cost taxpayers $180 million last year and served about 135,000 patients. The bill’s sponsors say too often rides are late or don’t show and they want to improve services and reduce costs.
Medicaid in the state, also called N.J. Family Care, greatly expanded under the federal Affordable Care Act. It now covers 1.7 million New Jersey residents, and Gov. Murphy’s budget is expanding services and benefits under the program.
As we’ve said before, adding more than half a million people who lacked health coverage to the program was great for them and the state. The challenge will be affording it. The federal government funded it all for awhile, but this year New Jersey will pay 10 percent of the cost of the expansion, up from 5 percent last year.
Capping reimbursement for non-emergency visits to hospital emergency rooms is one appropriate way to try to keep Medicaid affordable not just for its beneficiaries, but also for state taxpayers.