Healthcare advocates are raising questions about the impact on patients of a bill pending before Gov. Murphy that would cut payments to hospitals and emergency department physicians when Medicaid patients come to the ED for needs that end up being non-emergencies.

The bill, A-4207, establishes an emergency room triage payment of $140 for ED cases that are deemed “low-acuity.” The payment would apply to services delivered to Medicaid fee-for-service patients. Hospital EDs care for all patients who walk through their doors, and often times the symptoms that bring a patient to the ED – chest pains, for example – don’t always signal clearly whether it’s a health emergency. In addition, patients weigh many valid factors when choosing the ED or another setting of care for their healthcare needs.

Here's what leaders of healthcare and patient groups are saying:

Cathy Bennett, President and CEO, New Jersey Hospital Association
“Hospitals embrace their mission of providing quality care to all patients who present in their emergency rooms. Limiting payments based on information available only in hindsight is a disservice to patients and providers. We must guard against creating a climate in which patients’ decisions to seek ED care are second-guessed by payers. The risk to patients – and the financial impact on the emergency services that we all count on – is far too high.

“Emergency physicians have shared scenarios in which patients arrive at the ED with symptoms that may seem mild but require the full scope of triage and diagnosis to determine whether a far more serious condition exists:

• Example 1: A patient who suffered a head injury in a fall. Minor symptoms did not reveal an internal bleed that could only be determined if the hospital conducted a CT scan.
• Example 2: A patient who arrived with a low-acuity headache which turned out to be an aneurysm.

“Flu season is another key time for hospital EDs, which routinely handle the overflow of cases that can’t be seen in primary care offices, community health centers and urgi-care centers. Last flu season – one of the busiest in recent years – routinely saw New Jersey hospitals dealing with record levels of patients, both in their EDs and in their inpatient units. Bottom line: Patients turn to hospital EDs as their safety net when services are not available to them in other settings.”

Raymond Castro, Director of Health Policy, New Jersey Policy Perspective
“The Legislature’s intent to discourage inappropriate emergency room visits is laudable, but their proposal to cut Medicaid reimbursement by a total of $75 million for emergency room services will not solve that complex problem which requires a much more comprehensive approach. For example, the assumption is that consumers can simply see their primary doctor at any time for treatment instead of going to an emergency room. However, a lack of access to Medicaid providers has been a longstanding complaint in New Jersey, which is not surprising given that its Medicaid reimbursement rate is ranked the 48th lowest in the nation. In addition, it is concerning that this cutback is directed to the aged, blind and disabled who are the least likely to know whether their condition merits a visit to the hospital and are the most likely to need such care.”

John Poole, MD, President, Medical Society of New Jersey Board of Trustees
“When New Jersey residents are injured, in pain or in crisis, they need to access care immediately. Sometimes that means a trip to the emergency room. As physicians, we take our commitment to our patients very seriously, and that will never waver. But what this legislation would do, if signed into law, is unfair to patients and the physicians who care for them. A layperson should not be expected to know whether the symptoms they are experiencing are of ‘low-acuity.’ That’s our job. Many serious illnesses can begin with minor discomfort and exacerbate into serious medical conditions.

“But physicians and hospital emergency rooms are once again being asked to shoulder the burden for a shortcoming of the broader health system. Instead of enacting poor health policy, let’s work together to explore access-to-care issues in our state and make sure all New Jersey residents can receive the right care, in the right setting at the right time.”

Marjory Langer, MD, FACEP, President, New Jersey-American College of Emergency Physicians
"NJACEP strongly believes patients must have access to the right care at the right time. Emergency medicine physicians have long supported efforts for Medicaid to evaluate and improve access to community-based provider: FQHCs, dentists and primary care physicians. But the reality is even if the Medicaid network is adequate and offers same day/evening appointments, the Affordable Care Act under the 'prudent layperson standard' allows the patient to define the need for emergency care, not the ultimate diagnosis. When you come to the emergency room of a hospital you will be seen regardless of the condition you present with. This right was guaranteed by a federal law called Emergency Medical Treatment & Labor Act (EMTALA). Hospitals that offer emergency services are required to provide a medical screening examination when a request is made for examination or treatment regardless of an individual's ability to pay and then required to provide stabilizing treatment.  It is critical that New Jersey’s safety net physicians not be penalized for doing their job seeing patients 24/7/365.

“There are better long-term solutions on appropriate utilization of emergency departments that we would be happy to discuss with the Legislature and the Administration, however cutting payment to physicians for EMTALA-related activities is unsafe and hurting the state’s safety net of care."

Dr. Anthony DiFabio, President and CEO, Robin’s Nest
“Although appreciative of the Legislature’s desire to address patients choosing the right place for care with this bill, we should be cognizant that patients with mental health and substance use disorder needs account for nearly half of the growth in hospital emergency room cases in New Jersey hospitals. When patients with mental health and substance use disorder needs present in the ED, clinicians must engage in differential diagnosis. We need to ensure care and support appropriate diagnosis and safeguard against retrospective reviews that would reclassify ED visits as ‘low acuity.’”

Sister Patricia Codey, SC, Esq. - President, Catholic HealthCare Partnership of New Jersey
“Our mission as healthcare providers is to advance the healing mission of the Catholic Church, and to provide compassionate and proper care for our patients. Limiting a patient's choice in where and how they receive care only would negatively impact our already vulnerable populations. Capping an emergency room visit also limits our patients’ access to adequate healthcare, since many patients may seek healthcare services for what they think is a common cold, but it may end up being a life-threatening concern that would only be caught through thorough ED care.”

Jennifer Mancuso, Executive Director, Fair Share Hospitals Collaborative
“Fair Share Hospitals Collaborative (FSHC) members take pride in providing high quality care to all patients who visit our emergency departments, regardless of a patient’s insurance status or ability to pay. Asking a hospital to treat a patient differently based on a patient’s insurance status is contrary to our mission and further disadvantages an already vulnerable population. Hospitals should not be penalized for providing patients with a thorough and comprehensive evaluation to be sure the best possible health outcomes are achieved.”