After a contentious beginning, the state Medicaid program and a coalition of doctors and hospitals together forged a plan that helped cut nearly $34 million from expensive, unnecessary emergency-room visits last year, both sides announced Thursday.
The seven-point plan included connecting hospital emergency departments across the state so doctors can check if a patient is making multiple ER visits, perhaps getting duplicate scans and other tests, as they seek drugs or relief from a chronic condition better managed in a primary-care setting.
It also included a campaign to educate patients that “ER is for Emergencies,” as well as training for emergency doctors on how to help patients connect with primary care in the community.
The plan, put in place in 2012, was spurred by a startling proposal in 2011 by then-Medicaid Medical Director Dr. Jeff Thompson, who said costs of ER visits for nonemergency conditions were “way over the top.” He called for an end to reimbursements to hospitals and doctors after the third nonemergency visit by a Medicaid patient.
Doctors and hospitals quickly denounced the plan, saying it could harm patients.
The state chapter of the American College of Emergency Physicians, backed by Washington State Medical Association and the Washington State Hospital Association, filed a lawsuit in 2011 against the state. Early the next year, then-Gov. Chris Gregoire suspended the plan.
And then, everyone sat down at a table and came up with a plan to reduce unnecessary, expensive visits.
“We needed to have the state be the 900-pound gorilla in the room,” said Dr. Nathan Schlicher, an emergency-department doctor at St. Joseph Medical Center in Tacoma, who represented the state emergency-physician association.
“We couldn’t get those big institutions to play together, and the state, by being the 900-pound gorilla, broke down those silos and got us all to work together,” said Schlicher, a former state lawmaker.
An analysis of Medicaid-claims data from state emergency departments from June 2012 to June 2013 by the state’s Health Care Authority showed:
• Emergency-department visits by Medicaid patients declined by nearly 10 percent.
• The rate of visits by frequent clients (those who visited ERs at least five times a year) declined by nearly 11 percent.
• The rate of visits that resulted in a prescription for controlled substances decreased by 24 percent.
• The rate of visits for less-serious conditions decreased by more than 14 percent.
Rep. Eileen Cody, D-Seattle, chairwoman of the House Health Care & Wellness Committee, noted that lawmakers in 2012, facing a tight budget, included provisions to have hospitals implement the seven best practices developed by the planning group.
Budget writers took a “leap of faith,” she said, that the plan would save money, and prospectively cut Medicaid’s budget.
Dr. Daniel Lessler, state Medicaid’s chief medical officer, praised the effectiveness of the partnership.
“The big picture, to me, is that it means through public-private partnership and collaboration we can effectively improve health care.”
A prescription-monitoring program was key, he said, because it allows a provider to know if a patient has been receiving prescriptions from many other doctors.
“This is the ability to see the whole elephant,” he said. “It’s an extraordinary tool for all clinicians, but especially for emergency-department physicians.”
Emergency-department “high utilizers” often have multiple chronic conditions, both mental and physical, as well as psychosocial issues such as homelessness, he said.
“These are complicated patients,” said Lessler, who was a primary-care provider at Harborview Medical Center for more than 20 years.
Having information about a patient’s prior ER visits, Schlicher said, helped emergency doctors give better care, including avoiding duplicate scans and tests that could expose patients to unnecessary radiation or other risks.
Under the best-practices plan, emergency doctors still provided treatment, Schlicher said, but if a patient had been in ERs repeatedly for chronic migraines, a doctor could guide the patient to care more likely to provide a long-term solution and be more cost-effective.
“When you have a piece of data that says, ‘You have had 17 prescriptions from 11 different providers in the last three months,’ or ‘You’ve been in the ER 37 times in the last three months,’ it changes the conversation,” he said. “It gives individual providers the ability to tailor care during visits.”
In a statement, Dr. Dale Reisner, president of the Washington State Medical Association, said: “What’s best for patients is our top concern, and that includes providing care in the most appropriate and cost-effective setting.”
The cost savings achieved, said Dr. Stephen Anderson, an emergency doctor at MultiCare Health System, “came not from blocking access, but by coordinating care.”
Lessler cautioned that other changes during the study period, including such information-sharing efforts and the transition of Medicaid patients from fee-for-service plans to managed-care plans, may have played a role in the cost savings.
“But we know that in total, the costs were reduced by more than $33 million, and we know that a significant amount of the savings was because of these efforts,” he said.
There is plenty more to do, all players concede.
They’re hoping for more widespread adoption of a system to let primary-care providers know when their patients seek care in emergency departments.
So far, about 424 primary-care doctors are now connected, and about 3,000 notifications have been sent.
That program needs to be rolled out more broadly to primary-care providers around the state, Lessler said, and electronic systems need more integration. So the state, hospitals and doctors will continue their work. “We can do better.”