美國華盛頓州的急診醫師們對州政府提出控告!! Washington Docs Sue State over ED Visit Limits

美國的老人和窮人醫療保險制度


前篇文章簡介了一下美國的老窮殘醫療保險；Medicaid主要是由州政府承辦，對於窮人的醫療補助。


接下來是最近的新聞Washington Docs Sue State over ED Visit Limits

ref: http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/28826

主要是說州政府面臨預算赤字危機，決議要從州政府主辦的醫療補助Medicaid著手，減少支出。官方發現有部分民眾濫用了急診，造成整體支出上升；於是限制使用Medicaid的窮人們每年以＂非緊急病情＂到急診看診的給付次數為三次。


而華盛頓的急診醫師們提出抗議，根據聯邦法律EMTALA－據說這法案另外暱稱是反拋棄病人法－急診醫師們必須不論病人有沒有錢都要提供醫療照顧。如今州政府決定限縮給付，可是急診醫師又不能把病人趕走，那錢要找誰去要？


有沒有覺得跟台灣情形很像~~


其實有幾點可以觀察討論
1.州政府有提出配套措施和事前／事後排除條款
2.美國的EMTALA法案對急診室的影響
3.關於急診室是否被濫用，政府vs.急診醫師的態度，美國和台灣的看法是否不同？

Washington Docs Sue State over ED Visit Limits

Emergency physicians in Washington are suing that state's health department over a new law that limits the number of "nonemergency" emergency department visits that Medicaid will cover.

華盛頓的急診醫師們對於州政府的衛生主管單位提出控告；因為一項新的法律，限縮了使用窮人醫療補助 (Medicaid) 的民眾，在＂非緊急病況＂卻跑去急診看病的就醫給付次數。

The Washington State Health Care Authority recently notified Medicaid beneficiaries that starting Oct. 1, Medicaid will pay for no more than three nonemergency visits to emergency departments annually per beneficiary.

華盛頓州保健管理署最近通知了窮人醫療補助 (Medicaid) 的保戶，表示從10月1日開始，沒有＂緊急病情`"卻跑去急診看病，每年將只給付三次這樣的就醫費用。

Limiting emergency room visits is illegal, according to the lawsuit, which was filed by the Washington branch of the American College of Emergency Physicians (ACEP).

美國急診醫學會的華盛頓分部提出異議，表示根據相關的訴訟判決結果，限縮人民的急診就醫是違法的。

Washington's new law also would reclassify 700 diagnoses as "nonemergent" conditions,including chest pain, abdominal pain,miscarriage, and breathing problems, but ACEP is arguing that many of the codes represent true medical emergencies and should be covered by Medicaid, no matter how many times the patient has visited an ED during the year.

華盛頓州新的法律同時對於700項疾病診斷碼重新歸類為＂非緊急病況＂，包括了：胸痛、腹痛、流產、呼吸問題。但是美國急診醫學會反駁說很多疾病診斷碼事實上是代表了＂真正緊急的病況＂，應該包含在窮人醫療補助 (Medicaid) 的給付範圍，不應該限制病人每年的急診就醫次數。

"This list of nonemergent diagnoses puts patients in danger and unfairly targets the poor and those in most need of care," said Stephen Anderson, MD, president of the Washington Chapter of the ACEP, in a press release.

美國急診醫學會華盛頓分部的主席Stephen Anderson發布新聞稿表示：這份＂非緊急病況＂清單針對了那些最需要醫療補助的貧困民眾，不但不公平，甚至是導致他們處在危險之下。

The Health Care Authority spent nearly $98 million last year on 327,965 emergency department (ED) visits for Medicaid patients, according to a Sept. 22 press release.

根據9月22號發布的新聞，去年使用窮人醫療補助 (Medicaid)的民眾，總共有32萬7千9百6十5人次的急診就醫，同時花費了保健管理署將近98萬美元(編按：將近3億台幣)。

The three-visit plan is estimated to save the state $35 million a year.
The plan stems from a directive in the state's 2011-2013 budget that directed the Health Care Authority to find ways to cut unnecessary ED visits to save money.

這項＂三次就診限制計畫＂預估每年替州政府省下35萬美元(編按：約1億台幣)。這項計劃是根據2011-2013年的州政府預算要求，命令保健管理署找出辦法減少不必要的急診就醫來節省支出。

"This is a realistic strategy to change clients' behavior and improve patient care as well as assure taxpayers that we are addressing the state's continuing financial crisis," Doug Porter, director of the Washington Health Care Authority, said in the press release."Nonemergency issues and chronic conditions should be treated by a primary care provider, not by an expensive visit to hospital emergency rooms."

華盛頓州保健管理署主席Doug Porter在新聞稿中表示：＂這是個很實際的方案，一方面可以藉由改變受保民眾的就醫行為，同時增進病人照顧；甚至對廣大納稅人來說，這代表我們有努力在解決州政府越來越嚴重的財政危機＂。不緊急的問題和慢性疾病應該在基層醫療照護(Primary care provider)接受治療，不應該去花費昂貴的醫院急診就醫＂

The state is working with providers to develop alternatives, including opening up walk-in primary care clinics located near the hospitals and lining up case managers to work with EDs to find the right care for nonemergency patients, according to the press release

新聞稿同時表示，州政府目前與基層醫療照護單位合作發展替代方案，包括在醫院附近開設＂不需要預約可以直接看診＂的基層醫療診所；和招募個案管理師與急診醫師們合作研究出非緊急病患的正確照護方式。

The limit wouldn't apply to children who are in the foster system or living with relatives or other caregivers. Nor will it apply to patients brought in by ambulance,police, or emergency medical technicians; visits for mental health diagnoses or for clients seeking detoxification services; or for visits that result in inpatient admission, emergency surgery, or admission for observation.

這項限縮的政策，不會影響下列幾類病人：寄養系統、由親戚照顧、或是其他託育的兒童；經由救護車、警察、EMT送醫的病患；精神疾患或是戒毒酒癮戒斷患者；或是就醫診斷後需要住院、需要留院觀察、需要緊急手術的病患。

In addition to harming patients, the physicians argue in their suit, the limits will harm physicians. ED physicians must provide care under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) regardless of coverage rules, and will be penalized under the new law because they won't be paid for treating Medicaid beneficiaries who've exhausted their three-visit limit.

醫生們在提出的抗告中爭論，這項限縮政策除了對病患有害，也對醫生有害。根據聯邦法規《緊急醫療勞動法》(EMTALA)，不論病人是持有哪種保險、或是完全沒有保險，急診醫師都必須提供醫療服務；但是卻受到新的限縮政策懲罰，因為州政府對於超過三次就醫限制的窮人醫療補助 (Medicaid) 病患不支付醫療費用。

"Physicians also will suffer harm in that patients are likely to unnecessarily delay treatment, there by exacerbating the risks and costs of treatment and interfering with the patient-physician relationship," ACEP said in the lawsuit.

美國急診醫學會同時在訴訟中提到：＂這項政策讓病人容易遭受不必要的醫療延誤，因此增加治療上的風險和花費，影響了醫病關係，這樣的改變讓醫師受到危害＂

Washington Medicaid's chief medical officer, Jeffery Thompson, MD, said that 97% of Medicaid clients don't exceed emergency room visits in a given year, but that a "small number who exceed that limit are responsible for scores of visits," mostly for chronic conditions and pain complaints that result in a prescription for narcotic painkillers, he said in a prepared statement.

華盛頓窮人醫療補助 (Medicaid) 的首席醫療官Jeffery Thompson在準備好的聲明中表示：根據統計，97%的窮人醫療補助 (Medicaid) 保戶每年急診就醫次數不會過多；但是少部分的病患急診利用次數卻特別特別多，才造成整體就診人次上升。大部分都是慢性疾病和需要麻醉類管制止痛藥品處方的疼痛病況。

Washington's Medicaid office is working with a number of other states interested in developing similar policies, and if Washington state's policy goes into effect, other states may follow suit, Anderson said.

美國急診醫學會華盛頓分部主席Anderson表示，華盛頓窮人醫療補助 (Medicaid) 當局正在和其他有興趣的州合作發展類似政策；如果華盛頓州的政策開始生效，其他州可能也會跟進。