The perception that many people, in particular uninsured and Medicaid patients, use the ER inappropriately, is one reason why CMS proposed new rules to allow states to increase Medicaid cost-sharing for ER services. Of course, there is some truth to the assertion that a certain percentage of ER patients could, or should, get their care in a clinic, urgent care center, or primary care provider’s office. In many of these cases (though definitely not all), the cost of care would be lower. Considering for example the advantages of continuity of care, for some of these patients, the care might even be more appropriate, On the other hand, many attempts to divert patients from the ER, dissuade patients from going to the ER, or limit the services provided to patients who present to the ER, carry the potential for adverse consequences for providers, patients, the ER safety net, and the community. Any effort to reduce the inappropriate use of the ER must carefully weigh the possible risks and benefits of the strategy, and lean towards what is in the best interests of patient care.
Unfortunately, most of the strategies that have been adopted by State Medicaid programs, health plans, hospitals, and even some emergency physicians have been justified on the basis of myths about the impact of this inappropriate use on the overall costs of healthcare, the overcrowding of ERs, and the provision of unnecessary services. Just as important, strictly economic considerations (sometimes a reflection of fiduciary responsibility and sometimes an expression of pure greed) have often motivated the implementation of these strategies over any consideration of the risks to patients. Adoption of strategies to reduce inappropriate use of the ER have proceeded even in the face of clear evidence that the risk to patient welfare, and the ability of ER providers to meet their mission to provide care to everyone, regardless of insurance status, is significant. Like the assumption that insurance coverage guarantees access to care, the assumption that inappropriate use of the ER can be curtailed without adversely impacting access to needed emergency care, or the financial viability of the emergency care safety net, or the ability to train, recruit, and retain qualified emergency physician, NPPs, and ER backup specialists to staff our ERs, is all to often a mistaken assumption.
To identify valid strategies to reduce inappropriate use of the ER that can and should be considered, it helps to review what makes some strategies problematic. Here is a list of some faulty strategies promoted by Medicaid programs, and the adverse consequences they often entail:
- ‘Screen and street’, i.e. provide a brief screening at triage to identify ‘inappropriate use’ and either demand cash up front for treatment, or refuse further care. Besides potentially violating EMTALA (which requires a medical screening evaluation sufficient to rule out a medical emergency, something that may require extensive examination and testing), it may also be unethical, and puts some patients who do not have timely access to alternative venues for their care at serious risk.
- Reduce payment for non-emergency care in the ER based on retroactive review by payers. This process has the potential to generate millions of claims disputes, especially if the initial payment decision is based on ‘unapproved diagnosis lists’ rather than review of the medical record, to determine if the prudent layperson standard is met. Even the PLP is subject to interpretation and bias, and thus the strategy of payment reduction generates great uncertainty for providers, increases claims management, billing, and collection costs substantially, and may encourage hospitals and emergency physicians to inappropriately defer needed care.
- Increase co-insurance payments or co-pays for non-emergency visits to the ER, based on retroactive claims adjudication. Again, the retroactive determination by payers that an ER visit does not meet the PLP standard or is on a list of so-called non-emergency diagnoses, creates a claims management and collections nightmare for hospitals and ER physicians, and encourages these providers to second-guess these criteria, circumvent EMTALA mandates, and put patients at risk. It also discourages the poor from seeking ER care when they really need it.
- Denial of coverage for a non-emergency visit to the ER. Although insurers really should not have to cover the cost of an inappropriate visit to the ER, they often make these determinations without reviewing the medical record, or communicating with the enrollee to see if there was a valid reason to seek care in the ER. ER physicians frequently attempt to, or are asked to, intercede with the plan on behalf of these patients, and struggle to get patients to pay their bills when the plan denies coverage.
So what strategies to reduce inappropriate use of the ER make sense, and might be effective for Medicaid patients? Well, one strategy that State Medicaid programs and Medicaid Managed Care (MMC) plans should consider (but likely won’t) would be to quit worrying about these inappropriate visits, because in the overall scheme of things, they really do not result in major economic consequences, at least in comparison with all of the other ways that the health care dollar is wasted and misspent. Compared to higher acuity ER visits, care for patients in the ER who might be considered non-emergent is much less expensive, consuming far less resources in the ER. The cost of providing this care elsewhere also needs to be considered, especially when more than one visit to an office or clinic or lab is required to accomplish what is typically done in a one-stop-shopping single visit to the ER. Sometimes, care for non-emergency patients really does deserve to be provided after usual clinic hours; and the cost of running these after-hours services can be considerable. Lost time from work for patients or parents may not inure to the Medicaid program or MMC plan, but it still matters, especially to employers. Eliminating one unnecessary CT scan in the ER could pay for a raft of avoidable ER visits; but I recognize that the political pressure to eliminate these visits has so thoroughly permeated the health care debate that it has all but overwhelmed cost-effective care strategies that really could make a difference.
Therefor, in no particular order, here are some viable solutions that have a good risk profile for patients, and do not unfairly shift the financial and liability burden on to hospitals and providers:
- Identify ‘frequent fliers’, patients with who frequently use the ER, and enroll them in programs to better manage their clinical condition and limit their dependence on ER care.
- Have payers use their claims data to provide information about alternative sources of care to patients who appear to be using the ER inappropriately, and if this behavior continues, contact the patients directly to discuss these alternatives and assist patients in addressing the issues, be they transportation needs or access to after-hours clinics, or finding a ‘medical home’.
- Implement a reasonable co-pay for all ER visits, and allow hospitals to collect these co-pays while the patient is in the ER, and if the patient does not have the money to make this co-pay, collect it when the patient re-enrolls in the program and send it to the hospital. Patients should have some skin in the game, but not enough to deter them from coming to the ER when they need to come.
- Financially encourage Medicaid PCPs and clinics to provide services after usual business hours and on weekends, and ‘open access’ in their practices; and provide peer-profiling feedback to PCPs about the relative use of ERs by their patients.
- Establish 24/7 telephone nurse advice lines to Medicaid patients, with appropriate government subsidized liability coverage.
- Limit ER provision of narcotic prescriptions for chronic pain through strict guidelines, and facilitate the use of easy to access, up to date controlled substance monitoring programs.
- Mandate and enforce requirements that Medicaid Managed Care plans have adequate networks of urgent care and after-hours providers, and sufficient walk-in and same day appointment slots, to cover the need for these services by Medicaid enrollees.
- Compensate hospitals that provide on-site walk-in clinic and urgent care services at rates comparable to FQHCs, with appropriate Federal subsidies, so that hospitals can afford to provide these services on evenings and weekends to Medicaid and uninsured patients.
- Create a system to track primary care providers and clinics that accept new Medicaid patients, and provide open appointment slots for same day and next day followup referrals from ERs.
- Require not-for-profit medical groups to enroll a minimum percentage of Medicaid patients into their practices to qualify for not-for-profit tax treatment.
- Enroll Medicaid patients with chronic medical conditions, including chronic pain, in programs to prevent exacerbations, improve medication compliance, and keep PCP appointments.
- Provide online access to ER medical records across different facilities, so that providers can exchange information about patients who visit different ERs, and avoid the costs of repetitive testing and unnecessary care.
- Finance the opening of clinics staffed by volunteer providers in under-served areas.
- Provide post-ER-discharge educational information at follow-up appointments to help patients understand the appropriate use of the ER.
- Encourage local and regional partnerships between health clinics and hospitals to facilitate referrals, enhanced case management activities, and the provision of culturally appropriate primary care, transportation services, missed-appointment follow-up, and outreach.
The Association for Community Affiliated Plans published descriptions of some of these types of programs and policies in actual use, and in the State of Washington, an ongoing experiment to use some of these strategies has already demonstrated some success in reducing inappropriate use of the ER. It is tempting for State Medicaid programs to punish patients for seeking, and ER physicians and hospitals for providing, services in the ER that in retrospect could be provided for less money in other venues, in the hope that this will deter patients from inappropriately using the ER; but it is not the right way to accomplish this goal.