This AM, I read a post by an internist regarding the initiation by Washington State Medicaid that they will no longer pay for unnecessary ED visits, retrospectively. Welcome to Maryland. Although Medicaid hasn't initiated that restriction (but they are talking about comparable approaches) everyone else has. We lose money on virtually every Level I and Level II visit to our ED. We are required to treat every patient who comes through our doors; the law says so. If patients are triaged and determined to be non-emergent, try not treating them and getting them to seek care in an urgent or primary care setting. The media is already vilifying hospitals for such "aggressive" tactics, even though we are losing our preverbal shirts on "unnecessary" visits. And, it's only a matter of time before State Legislatures will begin passing bills prohibiting hospitals from employing such tactics. We are taking steps to keep these patients out of the ED. We are using care managers to work with our frequent flyers (those patients who are repeat visitors for unnecessary care to our ED). We are also looking at the social aspects of these frequent flyers and trying to address those needs. Population health continues to be a focus of hospitals in an effort to get our citizens healthier. The bottom line is that I find it interesting that our government has shifted this problem to hospitals and doctors because they (the government) can't afford it and in the process have tied our hands. Health care continues to be both an interesting and challenging business.