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Report: Penalties for Non-Emergency Use of ERs Based on Incorrect Assumptions

Using discharge diagnoses to determine validity of ER visits could have serious implications (Mar. 20)

Visits to the emergency room (ER) are not always for true medical emergencies — and some policymakers have been fighting the problem by denying or limiting payments if the patient’s diagnosis upon discharge is for “nonemergency” conditions.

Now a new study from the University of California, San Francisco challenges that framework by showing that criteria used as a basis to determine the appropriateness of an ER visit and to deny payment are inherently flawed. The study — published in JAMA — analyzed nearly 35,000 visits to hospital emergency departments around the country.

Overuse of the ER for nonemergency visits is often touted as a costly problem in the U.S. The new study highlights the complexity of the issue by showing that using discharge diagnoses to determine the validity of an ER visit could have serious implications, including dissuading patients from using the ER when they really need it. While many patients are given a diagnosis upon discharge that their condition was treatable through primary care, other similar patients actually required immediate emergency care or needed to be admitted to the hospital, the researchers found.

The authors concluded that strategies aimed at reducing the use of ERs are unlikely to improve a community’s general health or to lower health system costs.

“This study highlights the flaws of a system that fails to distinguish between information available at arrival in the emergency department and information available at discharge,” said lead author Maria C. Raven, MD, MPH. “Attempting to discourage patients from using the ER based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the ER for urgent or more serious problems.”

The authors said that, based on their findings, if a triage nurse were to redirect patients away from the ER based on so-called nonemergency complaints, 93% of those patients would not have had diagnoses treatable by primary care.

“An example of the problem would be a 50-year-old patient who wakes in the middle of the night with chest pain,” said senior author Renee Y. Hsia, MD. “He goes to the emergency department, and it turns out, luckily, he’s not having a heart attack but instead is diagnosed with acid reflux. It would be easy for a policymaker to look at his discharge diagnosis of ‘acid reflux’ and call that completely unnecessary, but the policymaker doesn’t know that the patient actually came in with a presenting complaint of chest pain. And we think such a visit is an appropriate one, and that such patients should come to the ER to seek care.”

Legislation or regulations to deny or limit payment, based on the discharge diagnosis, for nonemergency ER visits by Medicaid enrollees has been considered or enacted in Tennessee, Iowa, New Hampshire, and Illinois. Other states — including Arizona, Oregon, Iowa, Nebraska, North Carolina, and New Mexico — have recently implemented or considered copayments for nonemergency use of the ER.

Source: UCSF; March 20, 2013.

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