Reform Update: CMS offers strategies to fight rise in Medicaid ED visits

The CMS has released guidance it hopes will mitigate a potential increase in unnecessary emergency department visits by Medicaid beneficiaries because of the expansion of Medicaid under the Patient Protection and Affordable Care Act.

Experts predict at least an initial increase in ED use by people who previously were uninsured, have pent-up healthcare needs, and haven't had a regular healthcare provider other than the hospital emergency room. But some also say that problem will lessen over time as new Medicaid patients develop relationships with a regular provider.

The CMS guidance summarizes various strategies to direct patients to the most appropriate settings. The suggestions include broadening access to primary-care services and creating specific initiatives for frequent ED users. The guidance also provides regulatory insight to help distinguish non-emergency from emergency use of the ERs.

To broaden access to primary care, states could create more medical and health home programs. These typically offer extended hours on weekends and evenings, same-day appointments, 24/7 nurse advice lines, and continuity of care with one provider. This method worked for North Carolina. Its Community Care medical home program is credited with reducing the state's ED visit rate by 16% for asthma, with a total savings to Medicaid and the Children's Health Insurance Program of about $135 million.

The guidance follows the release of a state-by-state report card from the American College of Emergency Physicians that also predicted a rise in ED visits by Medicaid beneficiaries because they are likely to have a hard time finding physicians who will accept Medicaid patients.

It also follows a recent study that found Oregon adults covered by Medicaid initially used EDs 40% more than adults who were uninsured.

The CMS can help states support these efforts through enhanced federal funding under the Medicaid Health Home State Plan Option authorized under the healthcare reform law. The provision allows states to design medical homes to provide care coordination for beneficiaries with chronic conditions. A state also could create a unique model via a Medicaid Section 1115 waiver, the CMS said.

States also might create more alternative primary-care sites, including urgent care and retail clinics. Overall, it's estimated about 17% of all visits to hospital EDs could be treated at retail clinics or urgent-care centers, potentially saving $4.4 billion a year, according to a new RAND Corp. study.

These alternative primary-care sites also could help states control costs for “super-utilizers,” defined as individuals with four or more visits per year to an ED each year. That group represents 4.5% to 8% of all ED patients in the U.S. across all payers, but they account for 21% to 28% of all visits.

The CMS also tried to address the issue of when an ED visit is appropriate. There are statutes and regulations in place that incentivize providers to direct patients to more appropriate care settings. But they “can be challenging to implement in light of the difficulty in distinguishing upfront what is and is not an emergency,” the CMS said.

The agency simply cited the standard outlined in the federal Emergency Medical Treatment and Labor Act, which defines an emergency as symptoms that, in the absence of immediate medical attention, could reasonably be expected to place the health of the individual in serious jeopardy, or result in serious impairment of bodily functions or serious dysfunction of any bodily organ or part.

Some experts were unimpressed with the guidance. Joseph Antos, a healthcare economist with the conservative-leaning American Enterprise Institute, characterized it as “a PR move that doesn't actually give any additional authority or new ideas.”

Jason Hockenberry, an assistant professor in Emory University's health policy and management department, said the guidance doesn't address ED visits for Medicaid beneficiaries with mental health issues.

Shalama Jackson, a spokeswoman for the South Carolina Hospital Association, said the guidance outlined “a lot of work that we are already doing.”

In Arkansas, the Legislature's Joint Budget Committee is debating whether or not to end funding for the expansion of coverage to adults earning up to 138% of the federal poverty level. Continued legislative support of the program is in jeopardy after a Republican opposing the program won a recent special election for a state Senate seat. Republican conservatives are threatening to repeal the program. Hospital leaders are urging state officials to keep it in place.

The program, spearheaded by Democratic Gov. Mike Beebe, created a model that other conservative states have followed in expanding coverage under the federal healthcare reform law to low-income adults. The Arkansas waiver program, approved last year by the Obama administration, allowed the state to enroll adults earning up to 138% of the federal poverty level in private health plans through the federal insurance exchange. The private-plan model won support from just enough Republican legislators to pass. They opposed expansion of traditional Medicaid under the federal law.

The state Department of Human Services said it doesn't have a backup plan to maintain coverage for these low-income residents if lawmakers end the program. Beebe has warned that ending the program would leave nearly a $100 million hole in the state budget due to the loss of enhanced federal funding under the Medicaid expansion.

Follow Virgil Dickson on Twitter: @MHvdickson