NH puts hold on ER policy under Medicaid expansion

July 26--CONCORD -- The state's top health official agreed to rethink how up to 50,000 residents who are newly eligible for Medicaid would receive care in emergency rooms after hospital executives, doctors, and advocates for the poor and mentally ill criticized the proposal.

The Legislative Fiscal Committee voted overwhelmingly to set aside the policy change until September because it's widely seen as a linchpin to control costs even as the state offers taxpayer-paid insurance to low-income adults who have no coverage.

Senate President Chuck Morse, R-Salem, couldn't hide his frustration at the late arrival of the proposed change for the New Hampshire Health Protection Program.

"This is what is starting to drive me crazy about where we are headed right now," Morse said.

Enrollment in the program is set to begin Sept. 1.

Health and Human Services Commissioner Nick Toumpas said the matter should be studied further and that he'll consult with officials in Arkansas and Washington who have had success in reducing ER costs while expanding Medicaid.

"We all want to get this right the first time, and I'm committed to making this work because proper utilization of emergency rooms is a critical component," Toumpas said.

A key selling point made by Gov. Maggie Hassan and supporters to get the Legislature to expand Medicaid last spring was that it would be more cost effective to manage the health care of low-income adults than to have them visit emergency rooms for treatment.

Hospitals in the state gave more than $400 million worth of free or under-insured services to patients without proper health care coverage last year.

Senate Majority Leader Jeb Bradley, R-Wolfeboro, called the uncompensated care the "largest hidden tax" in New Hampshire.

Toumpas initially asked the House-Senate budget oversight panel on Friday to endorse his plan, which also requires final approval of the federal Centers for Medicare and Medicaid Services.

A significant concern raised by health care executives was for those not going to an emergency room to have access to health care 24/7.

"We control emergency room usage; that's the whole point of this," Morse said. "This document is useless right now because of everything that comes in behind it. We have to stand up another service, seven days a week, 24 hours a day, to let people come in. I am not comfortable with what is going on."

New Hampshire Hospital Association President Steve Ahnen raised another objection in that the plan relies on the judgment of a "reasonable layperson" with average knowledge of health and medicine to determine whether that person should go to an ER.

Initially, those newly eligible for Medicaid would be covered by one of two managed care organizations that supply care to the more than 110,000 who currently are on Medicaid.

"Naturally, hospitals are concerned that the MCOs might consider the subjective nature of the prudent layperson standard as a reason to deny payment for services," Ahnen wrote.

Elliot Hospital Vice President Richard Elwell said a reasonable person who has a headache or migraine might think he or she is having a stroke or aneurysm.

"If the state removes the subjectivity and applies 20/20 hindsight by looking at the final diagnosis versus the presenting symptoms or complaints, the provider has expended resources to care for the patient that may not be reimbursed," he wrote.

A coalition of advocates ranging from the New Hampshire Medical Society and New Hampshire Legal Assistance to New Hampshire Voices for Health and New Hampshire Fiscal Policy Institute argued the policy was too punitive for the client, who could be forced to pay out of pocket for inappropriate use of the emergency room.

They said national studies have concluded only 10 percent of emergency room visits by Medicaid clients were found to not be an urgent matter.

The same reports show those on Medicaid use emergency rooms at a rate almost double those with private insurance.

Denying Medicaid coverage for improper use of an emergency room could have unintended consequences, they said.

"Consequently, they may ration their care without regard to whether they should put off seeking medical care or in what context," they wrote.

Toumpas said he isn't concerned that the delay means the policy won't be in place when enrollment begins in six weeks.

"We will pay a flat member per month rate to these managed care organizations to provide care," Toumpas said.

"Until we get the language right, there's still going to be every incentive to ensure that every emergency room visit is justified. We're counting on the providers to collaborate with the managed care system so that clients receive the best, most cost- effective care."

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