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.