Utah Program curbs unnecessary trips to the ER

[willow18]

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http://www.sltrib.com/D=g/ci_15311668

By Kirsten Stewart

The Salt Lake Tribune
Updated: 06/16/2010 05:16:34 PM MDT

Some Utah Medicaid patients who made unnecessary trips to emergency rooms last year got a letter from the state stressing ER costs and urging them to find a primary care doctor.

If they visited an ER for routine care again, they received a second letter with a list of nearby urgent care clinics. After a third such visit, Medicaid officials placed patients on restricted access, which required them to see a family doctor to get prescriptions filled.

Dubbed Utah's Safe-to-Wait Project, the first year of the experiment is a success, state health officials say, curbing non-emergency use of ERs by 55 percent.

For some patients' care, that translated to an average monthly savings of $156.

It may seem a small sum considering the cost of the project, fueled by a two-year, $503,000 federal grant. But only a fraction -- 3 percent -- of Utah's 137,000 Medicaid recipients participated, and on a grander scale, the project would yield greater savings, Utah Health Department researchers predict.

And at a time when swelling health care costs threaten to consume state and federal budgets, every penny counts, said Gail Rapp, director of the state's Bureau of Managed Health Care.

Money isn't the only object; improved care is also the goal, said Melanie Jorgenson, a state restriction program coordinator.

This is related to what we've been discussing on other threads about screening low priority calls or restricting access to non-adherent patients. I wonder what "restricted access" means in this program. If an asthma patient comes in, for the umpteenth time, wheezing and SOB because he still hasn't gotten a PMD to write a monthly script for his inhaler (and tells me that he refuses to get a PMD because he "doesn't like doctors" and can come to the ED for scripts, true story), we can't just send him home, can we? How about if someone comes in with a silly headache for the 3rd time, but it turns out to be a tumor, who gets slapped with the suit?

 

[xaelia]

"Seeking care for a nagging headache or sore throat at the emergency room isn't a good way to get comprehensive care".

Well, no, it's not - it's a way to reduce mortality or morbidity. I'm all for reducing unnecessary visits, but this might not the philosophically ideal way to go about it. If they want to use the Emergency Department as an intervention location to schedule them urgent follow-up with their medical home after an emergent medical condition has been ruled out, that's fine.

I wonder how much of their cost savings would be offset by additional hospital charges resulting from delays in diagnosis - let alone the lawsuits from "well, my mom kept getting these letters saying she shouldn't go to the ER - and now she's on a long-term vent from her subarachnoid hemorrhage."

 

[december07]

From a legal standpoint, can you really take away someone's privilege of going to the ER? You can "recommend" for the patient to visit an FP first, but can you really restrict access to an ER? What if that 4th headache is a subarachnoid hemorrhage?

I'm glad Utah is thinking in the right direction, but I just don't see how this will stand from a legal standpoint.

 

[december07]

Hah, while busy reading the article, I had no idea Xaelia had already post a reply with an example of a subarachnoid hemorrhage as well 🙂

I guess we're on the same page.

 

[deleted109597]

So the patient shows up. EMTALA requires you to see them. Medicaid won't pay for the visit as the patient had a "letter". So the ED eats the cost effectively. It saves the state money. The patient won't pay any more.

Stupid rule. Won't change anything, but make ED visits non-paying for even more people.

 

[willow18]

So the patient shows up. EMTALA requires you to see them. Medicaid won't pay for the visit as the patient had a "letter". So the ED eats the cost effectively. It saves the state money. The patient won't pay any more.

Stupid rule. Won't change anything, but make ED visits non-paying for even more people.

If we only look at the dollars issue and put aside the legal implications, I don't think this would be a problem. The ED's can get reimbursed by Medicaid at the end of the year for all these "restricted" patients who show up anyway...the point is that "the system" saves money in the grander scheme.

 

[docB]

Well, no, it's not - it's a way to reduce mortality or morbidity.

Is it? I don't think we do a good job of delivering primary care and I'd wager the primary care we do deliver is frought with problems. People keep bringing up the dreaded headache that turns out to be SAH. But that's not a good example. The better examples would be the hypertensives and diabetics who need good, solid primary care but show up haphazardly at EDs. So one month they're on clonidine and the next lopressor with a gap of a week or two in between. They prefer to go to the EDs because it's free and there's no pesky appointments to deal with. But it's clearly worse care. Once they develop their headache with SAH then sure, let them in. But there are a lot of people who can be and need to be given a push toward their PMDs.

 

[roja]

Note-

The restricted access doesn't say they can't go to the emergency room:

After a third such visit, Medicaid officials placed patients on restricted access, which required them to see a family doctor to get prescriptions filled.

so if they do come to the ED and need a med refill, they can't get it filled until they ses a PMD.

 

[The White Coat Investor]

From a legal standpoint, can you really take away someone's privilege of going to the ER? You can "recommend" for the patient to visit an FP first, but can you really restrict access to an ER? What if that 4th headache is a subarachnoid hemorrhage?

I'm glad Utah is thinking in the right direction, but I just don't see how this will stand from a legal standpoint.

This is the beauty of it...you're not doing it so you're not liable...the government is. 🙂 Besides, the privilege to go to the ER is never taken away. You get a couple letters, then you can't get scripts filled without going to see your PCP. You can always go to the ER.

 

[GeneralVeers]

Since tort laws are controlled by the States Utah could conceivably exempt physicians for getting sued if they abide by the new guidelines and refuse to treat primary care complaints.

 

[deleted109597]

If we only look at the dollars issue and put aside the legal implications, I don't think this would be a problem. The ED's can get reimbursed by Medicaid at the end of the year for all these "restricted" patients who show up anyway...the point is that "the system" saves money in the grander scheme.

And if we ignore the sealevels rising we can get in on some bitchin' beachfront property at dirt cheap prices.

Problem is, this is a business. You can't go around practicing for chickens, no matter how much everyone's personal statement to medical school advocated for it. This is simply a way for the government to not pay for certain things. It's been discussed before, and they talked about doing something similar somewhere (Massachusetts?) before. As before, federal law says we must treat these patients. State courts turn around and state "these aren't emergent, and thus you shouldn't have done x, y, and z". Then they don't pay for x, y, or z. However, we can't assume everyone who comes in doesn't have an emergent condition. It's the nature of the practice. So while we don't need to radiate them all, we still need to evaluate them. And soon we will be doing it for free.

 

[GeneralVeers]

As before, federal law says we must treat these patients. State courts turn around and state "these aren't emergent, and thus you shouldn't have done x, y, and z". Then they don't pay for x, y, or z. However, we can't assume everyone who comes in doesn't have an emergent condition. It's the nature of the practice. So while we don't need to radiate them all, we still need to evaluate them. And soon we will be doing it for free.

Actually Federal law makes no such statement. The Federal law simply provides for a medical screening exam for every patient. It only provides for treatment and stabilization of emergent medical conditions.

 

[deleted109597]

Veers is correct, they don't mandate we treat anything non-emergent. I was trying to mean "see", but couldn't come across how to put it. I guess evaluate would work.
However the "screening exam" portion has never been delineated very well, so most places simply perform some cursory history and physical. And since my facility mandates from on high that every chart be able to be billed at a level 5 (which increases my time spent documenting immensely), most people aren't given only a screening exam by qualified medical personnel as mandated by EMTALA. So they are billed for a visit, even if no testing or interventions are performed. I don't even know if there is a code for screening exam.

 

[docB]

Veers is correct, they don't mandate we treat anything non-emergent. I was trying to mean "see", but couldn't come across how to put it. I guess evaluate would work.
However the "screening exam" portion has never been delineated very well, so most places simply perform some cursory history and physical. And since my facility mandates from on high that every chart be able to be billed at a level 5 (which increases my time spent documenting immensely), most people aren't given only a screening exam by qualified medical personnel as mandated by EMTALA. So they are billed for a visit, even if no testing or interventions are performed. I don't even know if there is a code for screening exam.

In my group we do a full H&P/T sheet. If we deem them non-emergent we (the physicians) don't bill them and they don't get charged the facility fee by the hospital. They do get charged a "triage charge" which is ~$75 but that's way less than the minimum ~$500 facility charge.

 

[Raryn]

In my group we do a full H&P/T sheet. If we deem them non-emergent we (the physicians) don't bill them and they don't get charged the facility fee by the hospital. They do get charged a "triage charge" which is ~$75 but that's way less than the minimum ~$500 facility charge.

Does any portion of that triage charge go towards the physician(s)?

 

[docB]

Does any portion of that triage charge go towards the physician(s)?

No. The theory was that we would be picking up even more risk by billing a patient who is undoubtedly pissed off at us for telling them they are non-emergent.

 

[doctorFred]

No. The theory was that we would be picking up even more risk by billing a patient who is undoubtedly pissed off at us for telling them they are non-emergent.

i dunno. if a person's already pissed off, do they really differentiate between being billed 75 from the hospital versus 60 + 15 from the doc? you did evaluate them after all.

 

[pinipig523]

From a legal standpoint, can you really take away someone's privilege of going to the ER? You can "recommend" for the patient to visit an FP first, but can you really restrict access to an ER? What if that 4th headache is a subarachnoid hemorrhage?

I'm glad Utah is thinking in the right direction, but I just don't see how this will stand from a legal standpoint.

When you are paying for their care, you can limit their benefits. Just because you have a car doesn't mean you can go however fast you want. There are speed limits, there are speed tickets, and there are license suspensions.

 

[deleted109597]

i dunno. if a person's already pissed off, do they really differentiate between being billed 75 from the hospital versus 60 + 15 from the doc? you did evaluate them after all.

Because it doesn't work that way. It is the difference of being billed 75 vs 75+x for the physician fee. The hospital isn't going to take less because the physician is billing.

 

[doctorFred]

Because it doesn't work that way. It is the difference of being billed 75 vs 75+x for the physician fee. The hospital isn't going to take less because the physician is billing.

raryn asked whether or not a portion of the 75 was going to the physicians, and docb answered no, a portion of the 75 is not going to the physicians. "it doesn't work that way" doesn't mean "it can't work that way."