Washington state's new plan to limit Medicaid patients to three nonemergency visits to the emergency room each year will put the most vulnerable members of society—including children—at risk of serious harm, three statewide organizations assert.

The organizations issuing the warning are the Washington chapter of the American College of Emergency Physicians, the Washington State Medical Association, and the Washington State Hospital Association.

The state is taking away coverage for more than 700 diagnoses that have symptoms of serious medical conditions, including chest pain, abdominal pain, miscarriage, and breathing problems. While the state classifies many of these conditions as nonemergent, physicians and health care experts don't agree. The list of conditions the state is adopting was generated solely by the state Medicaid office over the objections of physician and hospital task force representatives.

"The symptoms of many of these medical conditions indicate life-threatening emergencies, and people with these symptoms should seek emergency care," says Dr. Stephen Anderson, president of the emergency physicians group. "Not doing so could lead to severe illness, disability, and even death. Including conditions such as congestive heart failure, kidney stones, miscarriage, chest pain, and asthma is outrageous and dangerous."

Dr. Doug Myers, president of the state medical association, agrees.

"Severe chest pain can be a symptom of a heart attack or an esophagus problem that is not an emergency, but the patient cannot self-diagnose," says Myers. "Limiting Medicaid patients to three emergency department visits poses a significant threat to patient safety, leaving many to avoid or delay seeking needed emergency care in fear it will be deemed a nonemergency and they will exceed the allowable limit. The end result of this kind of policy will be the need for prolonged and more intensive care, which not only harms the patients, but increases costs for everyone."

The legislatively enacted policy, physicians contend, unfairly targets children and the state's most vulnerable citizens. Two-thirds of the state's 1.1 million residents covered by Medicaid are children, and the proposed plan would significantly affect them, the opposing organizations' leaders contend.

Prudent layperson standard

The plan, which was developed by the legislature and signed by Gov. Chris Gregoire as part of the 2011-2013 state budget, undermines the prudent layperson standard under both federal and state law, they argue. These standards require health plans to cover visits to emergency departments based on an average person's belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis.

The prudent layperson standard in federal and state law is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with acute care or a nonemergent medical condition.

The prudent layperson standard addressed the severe problem of retrospective denials of emergency care by health plans, and protected patients from having to self-diagnose their medical conditions out of fear of receiving a bill when they sought care for symptoms that are often emergent and life-threatening. The federal standard also required Medicaid-managed care plans not to set limitations on the number of emergency visits that they'll cover.

Critics contend the new policy means that Washington Medicaid fee-for-service clients won't receive critical prudent layperson protections that are required for patients of all Medicaid-managed care plans across the country, all private health plans as mandated by the Patient Protection and Affordable Care Act, and all federal military and civilian employees mandated by a presidential executive order. And unlike all other citizens in the state, Medicaid fee-for-service clients who suffer chest pain or any one of more than 700 conditions can't know if their care will be covered, and thus will be discouraged by the state from seeking care that could be needed to save their lives, the organizations assert.

"We are not blind to the budgetary challenges facing our state," Myers says. "We expected to work closely with state officials to come up with a list of truly nonemergent conditions. But we are not willing to sacrifice patient safety and many of these cuts pose a dangerous and significant threat to the safety of our patients."

Dr. Nathan Schlicher, a practicing emergency physician and health care attorney in Tacoma, says, "There is a real possibility of expensive litigation against the state for implementing a plan that on its face contradicts federal and state law. It is our duty to protect our patients while caring for them in the emergency department, and now we may have to do so in the courtroom."