State initiative trims ED utilization
Care coordination model does not deny access
While the beginning stages of the effort may not have been pretty, Washington state’s coordinated program to tamp down costs related to high ED utilization by Medicaid recipients has not only exceeded expectations in terms of cost savings, now emergency medicine professionals are eager to apply the partnerships formed as part of the approach to other health care problems. And why not? The infrastructure and the relationships are in place. And leaders of the ER is for Emergencies effort are eager to use the new tools at their disposal to bring more value to the table. With $33.6 million in Medicaid savings to report in the program’s first year, it is no wonder why providers and policymakers from other states are eyeing the program as well.
However, it is worth remembering that what prompted the effort in the first place was a proposal made in 2011 by the state’s Medicaid chief to put a lid on the number of "non-emergency" ED visits the state would pay for, leaving hospitals on the hook for any additional "non-emergency" visits. The state chapter of the American College of Emergency Physicians (ACEP) filed suit against the state with backing from the Washington State Hospital Association and the Washington State Medical Association.
The proposal was put on hold while hospitals and physician providers came up with an alternative plan involving the implementation of seven best practices. Getting all the hospitals and EDs in a state to act in concert is never easy, but with the threat of non-payment hanging over their heads, they all participated.
Create a shared vision
While tempers were heated at the time, to say the least, emergency providers concede that state pressure is what pushed them to make needed reforms. "It was sort of the sword of Damocles over our heads that motivated change," says Nathan Schlicher, MD, FACEP, JD, associate director of the ED at St. Joseph’s Medical Center in Tacoma, and one of the leaders of the ER is for Emergencies program. "It allowed us to save costs for the state, but in a way that enabled hospitals to save money by lowering their staffing if their volumes went down. The alternative with the state plan was to say you keep providing care, and you keep paying for it, and we are not going to pay you."
While ED volumes did go down significantly, each hospital was able to change its staffing to meet the new level of care rather than just face less reimbursement while providing more care, explains Schlicher. "With the overcrowding that exists in EDs across the country — and we have it here in Washington — this allowed many institutions to avoid having to do very expensive and massive remodels," he says. "So the incentives aligned well with doing the right thing, and I think that is what we needed: having a shared vision and a shared goal set, but then allowing the experts in the field — the providers of care — to figure out how we get there."
In addition to relieving pressure on the state’s Medicaid budget, the "ER is for Emergencies" initiative also helped the state chart impressive gains on several other metrics. The Washington State Health Care Authority reports that an analysis of claims data for ED activity between June 2012 and June 2013 shows that:
• the rate of ED visits by Medicaid recipients declined by 9.9%;
• the rate of visits by frequent utilizers (five or more visits per year) declined by 10.7%;
• the rate of visits resulting in a scheduled drug prescription fell by 24%;
• the rate of visits for a low-acuity diagnosis declined by 14.2%.
Anticipate challenges
From the start of the initiative, the biggest challenge was obtaining administrative buy-in to implement the seven best practices, explains Stephen Anderson, MD, FACEP, an emergency physician at MultiCare Auburn Medical Center in Auburn, and past president of the Washington chapter of ACEP. "We were going to administrations and saying that we needed them to spend money on infrastructure, and what we also needed them to anticipate is that by doing so, they would also see a drop in volume," he says. "That doesn’t play out in the economic back rooms real well, so it was really critical that we had the whole team on board. We had the back-up of the Washington State Hospital Association going into this."
A second challenge involved getting all the primary care providers (PCPs) in the state to understand the process, and this continues to be a work in progress, made more difficult by the fact that Medicaid does not reimburse well for primary care visits, says Anderson. "Clearly, it is a challenge to see some of the high utilizers that we have; they are high time-intensive patients," he says. "So explaining the seven best practices — [and in particular] what is called the PRC program — patients requiring coordination to primary care, and really pushing for that early follow-up within 72 hours was difficult." However, Anderson adds that the task was manageable because the initiative had the backing and support of the Washington State Medical Association.
Getting all the emergency providers in the state to support the initiative did not take long, given that they were well aware of the state’s non-payment alternative, says Anderson. But he also notes that providers were getting some tools that they had long requested, including the state’s new prescription monitoring program (PMP) and the Emergency Department Information Exchange (EDIE). These tools give providers information about a patient’s previous prescriptions and previous visits to EDs throughout the state.
Further, anticipating some of the issues that could result in cases in which emergency physicians decline to write prescriptions for patients identified as drug seekers, leaders of the initiative coached emergency providers with sample conversations, and they also created a letter providers can give to their administrators in anticipation of any patient complaints related to the denial of narcotic prescriptions. (To view the letter, visit http://www.washingtonacep.org/educationresources.html. Find the link at the bottom of the page.)
"Once we gave our providers the tools they were asking for, they bought into this really quickly, and part of that was having the Washington State Chapter of the American College of Emergency Physicians behind the effort," says Anderson.
Making sure consumers understood the initiative created some hurdles, says Anderson. For instance, in consultation with the Centers for Medicare & Medicaid Services (CMS), providers worked and reworked an educational poster to make sure that it didn’t present any obstacles to patients prior to the medical screening exam. They also created pamphlets and videos to explain the initiative to patients.
Consider impact on patient volume
Interestingly, while state-level numbers show that ED volume is down, it’s clear that the initiative did not affect all EDs in the same way. For instance, ED volume is up slightly at Providence Regional Medical Center (PRMC) in Everett, ccording to Enrique Richard Enguidanos, MD, FACEP, an emergency physician at PRMC and president-elect of the Washington chapter of ACEP. He attributes at least some of that uptick in volume to implementation of the Affordable Care Act (ACA). "That has been our experience," says Enguidanos. "We have seen a bit more utilization in the last three or four months. We are monitoring it very closely."
Another potential reason for the consistent volume at PRMC is that the ED was already actively involved in case management when the ER is for Emergencies initiative was launched. "We are probably the biggest ED that does case management in the state. And we already had that going, so that [aspect of] the initiative wasn’t as important to us," says Enguidanos. "However, what really helped us was the state implementation of the Emergency Department Information Exchange [EDIE], which allowed us to view cases from across the state for individuals who came in. We knew if they had a management plan, and we knew how to get a hold of their provider, so that was extremely helpful, and it provided much better care for patients."
While PRMC saw little change as far as patient volume is concerned, the ED at MultiCare Auburn Medical Center in Auburn saw volume drop by more than 13%. Anderson suggests this is because the hospital serves a largely blue collar population that includes a high number of Medicaid recipients. "We actually even closed our fast track because our low-acuity visits decreased by at least 15%," he says. Anderson adds that his ED saw a reduction of at least 12% in visits by frequent utilizers.
Anderson does not attribute all of these decreases to the ER is for Emergencies initiative. There were also new care options available to consumers when additional urgent care centers opened in the region. Further, he notes that the hospital was in the process of being sold, and providers were also just going live with a new electronic medical record system.
While there were many contributing factors, Anderson acknowledges that providers did have to accept a loss in income from the reduced volume. "We made a conscious decision that we were going to do this right because we ultimately hoped if the ACA took off and was successful in our state, then the number of our private pay/no insurance patients would decrease," he says. "And now our volumes are starting to go up a little bit."
Patient volumes could well continue to rise. Reports suggest that by the end of March, more than 285,000 newly eligible adults had signed up for Medicaid coverage in Washington this year — far more than the state had anticipated.
There is more to do. Technical improvements to make the information-sharing aspects of the initiative faster and more efficient are planned. Further, there is currently nothing to stop drug-seeking patients from crossing state lines to visit EDs that do not have access to Washington state’s EDIE, but such behavior may be short-lived. "Oregon is looking at implementing our program, and possibly even integrating with the system we use so that we would have shared visit records, and that way we would be able to see beyond those border communities," says Schlicher. "The key thing is that through all of this no one has been denied access or care. No one has been told they shouldn’t be in the ED. Instead, we have created an environment that says the place for primary care is your PCP’s office, and we would like to make sure that we get you there."
Anderson’s advice to providers and policymakers in other states that are struggling with the same issues is to remember that success comes not from blocking access, but from coordinating the care of patients. "You really need to build an infrastructure that allows hospitals, PCPs, and care managers to coordinate the care — initially of high-utilizers and then all ED patients," he explains.
Further, while some economic input is needed to build the infrastructure, Anderson stresses that all the interested parties need to participate to make it work. "Get them to the table because cooperation is going to get you a whole lot further than arguing your own point without being able to realize that times are changing," he says. "When we stopped fighting in the media and the courts, and finally sat down and considered what will work to decrease low-acuity visits and high-utilizer return visits, it wasn’t rocket science."
Enguidanos offers similar sentiments. "There is so much that gets done in medicine where all the parties involved think they are doing the right thing, but they don’t understand the nuances of the other entities involved," he says. "In our case, Medicaid really had great things in mind, but I don’t think they realized how their initial proposal was truly going to impact the patient coming into the ED and ED care. But once we were able to get Medicaid to sit down with the ED physicians, and then the hospital and medical associations, then we all started to understand the different perspectives."
With the results thus far exceeding expectations, emergency providers are eager to see colleagues in other states follow a similar path. "Right now, the system we have in Washington in terms of the EDIE, the prescription drug monitoring program, and the feedback reports, is arguably the envy of emergency medicine," says Schlicher. "It is what we have always dreamed of: the ability to know what is best for our patients, and to be able to get data on their medical history so that we can provide the best, most accurate care. Now we have that option."
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