EMTALA and Health Care Reform Scott Smith University of Utah Office of general counsel

ED Visit Trends Since the 1990s, the number of ED visits has steadily increased The growth in ED visits has outpaced the growth of the general population, despite a national decline in the total number of ED facilities The number of ED visits covered by Medicaid has steadily increased Sources: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-Visit-Trends.pdf https://www.hcup-us.ahrq.gov/reports/statbriefs/sb174-Emergency-Department-Visits-Overview.pdf

Between 2006 and 2014, there was a 66% increase in ED visits covered by Medicaid, and a 10% decrease in visits covered by private payers Source: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-Visit-Trends.pdf

The Vision of the ACA One of the key goals of the ACA was to increase coverage through: Medicaid expansion Creation of subsidized private insurance markets Dependent coverage Etc. Proposed benefit: Greater access to primary care, which means folks: Seek care early (before a condition becomes emergent and requires a trip to the ED) and Do not treat the ED as their primary care clinic

Has it worked? Studies are all over the board: Some say the ACA may or does reduce ED use Others say the ACA has had no significant impact on ED visits And others say the ACA has increased ED visits ACEP poll: 75% of emergency docs say they’ve experienced an increase in patient volume after 2014; and 56% report an increased Medicaid volume specifically Takeaways: The relationship between health insurance coverage and ED use is complex. Whether someone uses an ED or not likely depends on a variety of factors, including the characteristics of the patient (e.g., age, income, health status), the insurance plans covering those patients (e.g., cost sharing obligations, generosity of provider payments, network adequacy, etc.), and the geographic location where those patients live and receive care. Even if health care reform reduces ED use, it may not reduce the overall use or cost of services. At best, we may see a more efficient allocation of spending with less ED use and more outpatient care.

Policies to Reduce ED Visits (and Costs) Limit the number of ED visits per year E.g., Florida’s 6 visit ED cap for Medicaid beneficiaries Limit or deny payment for unnecessary ED visits E.g., BCBS payment denials in Texas, Ohio, Georgia E.g., NJ proposal to cap Medicaid reimbursement to hospitals Broaden access to primary care services or urgent care services Deloitte: markets with a higher concentration of urgent care centers have lower ER visit rates Educate patients (especially “super utilizers”) and direct them to appropriate care settings E.g., Washington statewide patient data exchange system Hospitals are on the hook Some of these policies put the burden on hospitals, which seems unfair because hospitals can’t control who shows up at their doors

EMTALA Can Deter Cost-Saving Methods Hypothetical 1: A patient with a cough comes to an ED that is not in the same physical building as the health system’s urgent care clinic. Can the ED redirect the patient to the urgent care clinic? Providers cannot redirect a patient from the ED to urgent care, unless they are in the same physically contiguous space.

EMTALA Can Deter Cost-Saving Methods Hypothetical 2: A patient comes to an urgent care clinic with a bad fracture. The clinic screens and stabilizes the patient as required by EMTALA, even though it isn’t the best provider to treat the patient. The patient then goes to the ED to get the fracture treated. Who will bill the patient? Urgent care sites are subject to EMTALA if they are (1) licensed as an ED; (2) hold themselves out as a place that provides urgent/emergency conditions without needing an appointment; or (3) 1/3rd or more patients are walk-ins.

EMTALA Can Deter Cost-Saving Methods Hypothetical 3: A patient is being transported by ambulance to a psych hospital, Hospital A. The patient would rather go to Hospital B because his insurance coverage is better at Hospital B. Can the patient be redirected to Hospital B? Providers cannot redirect a patient based on the patient’s insurance status or ability to pay.