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News & Politics News & Politics

How many ER visits does anyone need in a year?

Posted by on Mar. 3, 2014 at 3:29 PM
  • 24 Replies

TALLAHASSEE -- Florida has been limiting Medicaid patients to six emergency room visits a year even though federal officials consider such a cap illegal.

As a result, the federal government intends to penalize the state by withholding a portion of Medicaid funding.

"We hope the state will realign their Medicaid program with federal standards to avoid this penalty," said Emma Sandoe, a spokeswoman for the Centers for Medicare and Medicaid Services.

The Florida Agency for Health Care Administration is in the midst of an appeal of the federal government's rejection of the six-visit limit. A September hearing is scheduled.

But while the fight has been pending, the state agency went ahead with its plan.

"We are concerned that CMS is prejudging this matter by seeking to impose administrative penalties" before the appeal has played out, said spokeswoman Shelisha Coleman.

"It's unfortunate that despite a September hearing to resolve the matter CMS is withholding matching funding," said Frank Collins, communications director for Gov. Rick Scott.

Federal officials did not estimate how many people have been denied Medicaid coverage for emergency room visits.

Of all Medicaid patients who visit the ER, less than 1 percent go more than six times a year, according to state estimates.

In addition, the rule applied only to patients on traditional Medicaid. Most Medicaid patients are being shifted to managed care plans.

It's unclear yet how much the state could be penalized. CMS says it will initially withhold 10 percent of whatever the state claims for certain administrative costs. That amount will go up 5 percent each quarter while the state remains out of compliance.

Limiting the number of ER visits is intended to be a cost-saving measure. Republican lawmakers in 2012 said it would encourage patients to rely on primary care doctors instead of hospital ERs.

Scott proposed the annual cap on visits be 12 a year, though it was eventually reduced to six for non-pregnant adults over age 21.

But Florida needed federal permission. In December 2012, the Centers for Medicare & Medicaid shot down the initiative.

Such limits on ER visits, the federal agency says, violate the Social Security Act by "arbitrarily" denying coverage of a mandatory benefit and would not be in patients' best interest.

The state appealed the denial in February 2013. Federal officials say while working through the appeal, they learned that the state had gone ahead and put the limits in place.

by on Mar. 3, 2014 at 3:29 PM
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Replies (1-10):
sheramom4
by Member on Mar. 3, 2014 at 3:33 PM

When my husband first started having physical health issues from his time in the service he was there several times in a two year period. At least monthly, and some months weekly. He had uncontrolled asthma, h-pyloria (which took 18 months to diagnose), ended up with an ambulance ride when he passed out and smacked his head due to  undiagnosed vertigo and caught H1N1. He uses the VA system and unfortunately, they do not have an urgent care or same day service so it is the ER or waiting up to three months for an appointment. Although most of these were ER worthy issues.

SallyMJ
by Ruby Member on Mar. 3, 2014 at 3:50 PM

People with asthma and COPD are screwed.

UpSheRises
by on Mar. 3, 2014 at 4:15 PM

It took me about a year to get a diagnosis of Cyclical Vomiting Syndrome. I had a primary care physician and also saw a gastro many, many times over that year. I went to ER many, many times. I can recall going and still having the bracelet on from the last time i was there. It's not an exaggeration to say that i barfed for 3 or 4 days straight, every 45 min., have 2 no-barf days, then do it all again for 4 days. I was in bad shape. 

So i guess, if someone has a condition like i do, that can take a while to diagnose and has acute and severe episodes, they might need to go a lot.

mcdun
by Humboldt California on Mar. 3, 2014 at 8:56 PM

My husband's insurance (the one he had through work) limted us to 2 visits per year. So 6 is pretty damn good! Of coarse I wasn't even allowed on the plan because of preexisting conditions. 

Now we have Obamacare and no longer worry about those things and pay much less then we did and I'm actually covered. 

I  bet  you  make  your  daddy  proud

Analeigh2012
by Silver Member on Mar. 3, 2014 at 11:42 PM

I can see where there should be limits on ER visits.  For non-emergent cases, there is no reason to see the ER.  It is inflated costs.  For example, I had to wait 2 hours at an ER when I nearly sliced my thumb off.  There was a little boy, about 10, ahead of me that had cut his head open.  We sat there bleeding while we saw case after case of people claiming their back was sore where they had hurt it at work 5 days ago; a woman with a migraine; a guy who had gotten stitches and needed them removed - he had missed hus doctor's appointment and at that point they were closed for the day.  I didn't mind waiting for the elderly man experiencing difficulty breathing - but the others were non-emergency cases and should have seen a primary care doctor.  If there was restrictions, that would alleviate the crowding in ERs.  

Ziva65
by Bronze Member on Mar. 4, 2014 at 2:51 AM

This is happening with Medicare too- their physician will be financially penalized for frequent ER fliers. That's one reason insurance companies are hiring NP's and PA's to follow these patients, it's also a reason they are trying to get EMT's to start managing chronic conditions.

Has anyone else noticed if you call 911, they ask now "have you been to the ER lately? SCARY.

It's all a result of Obamacare- got to trim services and save money somehow... the true chronic conditions will have issues. :(

IhartU
by Bronze Member on Mar. 4, 2014 at 9:28 AM


Quoting Analeigh2012:

I can see where there should be limits on ER visits.  For non-emergent cases, there is no reason to see the ER.  It is inflated costs.  For example, I had to wait 2 hours at an ER when I nearly sliced my thumb off.  There was a little boy, about 10, ahead of me that had cut his head open.  We sat there bleeding while we saw case after case of people claiming their back was sore where they had hurt it at work 5 days ago; a woman with a migraine; a guy who had gotten stitches and needed them removed - he had missed hus doctor's appointment and at that point they were closed for the day.  I didn't mind waiting for the elderly man experiencing difficulty breathing - but the others were non-emergency cases and should have seen a primary care doctor.  If there was restrictions, that would alleviate the crowding in ERs.  

 When I was little it was like that.  I sliced my foot open when I was 7 and had to wait 6 HOURS in the ER bleeding and crying before I got stiched up.

 Now, when you go to the ER, a Nurse sees you and decides if it's a real emergency or not and if it's not, you're sent up the ramp to another part of the ER to be seen; they separate you accordingly which is nice. I've gone to the ER many times with kidney stones and don't think I would have been able to sit in the waiting room without sceaming for more than 5 minutes!

Analeigh2012
by Silver Member on Mar. 4, 2014 at 10:47 AM
This was not when I was a child, this was last year. Our hospital is a really good one, but smaller. They did not separate. I know what people had wrong because the triage desk was right in front of me. Now, when my husband had a series of TIAs and I rushed him there, as soon as I told the triage nurse he was presenting like a heart attack or stroke, they immediately wheeled us through to a room and there was no waiting - they had him hooked up to machines before the door closed behind us - they were awesome. But, unless it is chest pains or trouble breathing or amputation, you sit and wait your turn. My whole point though is that if people were restricted from going to the ER for non-emergent cases, that would not be a bad thing.

Quoting IhartU:

Quoting Analeigh2012:

I can see where there should be limits on ER visits.  For non-emergent cases, there is no reason to see the ER.  It is inflated costs.  For example, I had to wait 2 hours at an ER when I nearly sliced my thumb off.  There was a little boy, about 10, ahead of me that had cut his head open.  We sat there bleeding while we saw case after case of people claiming their back was sore where they had hurt it at work 5 days ago; a woman with a migraine; a guy who had gotten stitches and needed them removed - he had missed hus doctor's appointment and at that point they were closed for the day.  I didn't mind waiting for the elderly man experiencing difficulty breathing - but the others were non-emergency cases and should have seen a primary care doctor.  If there was restrictions, that would alleviate the crowding in ERs.  

 When I was little it was like that.  I sliced my foot open when I was 7 and had to wait 6 HOURS in the ER bleeding and crying before I got stiched up.

 Now, when you go to the ER, a Nurse sees you and decides if it's a real emergency or not and if it's not, you're sent up the ramp to another part of the ER to be seen; they separate you accordingly which is nice. I've gone to the ER many times with kidney stones and don't think I would have been able to sit in the waiting room without sceaming for more than 5 minutes!

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PamR
by Platinum Member on Mar. 4, 2014 at 3:13 PM

That would depend on the particular circumstances of the person visiting the ER - their health, conditions, etc.

timeforprogress
by Bronze Member on Mar. 4, 2014 at 3:32 PM

Does the patient have a chronic illness?

Does the patient work in a dangerous field?

Does the patient live in dangerous conditions?

I can come up with plenty of scenarios that would cause me to consider this procedure unjust.

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