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HOSPITAL EMERGENCY DEPARTMENT USE AND ITS IMPACT ON THE STATE MEDICAID BUDGET

Program Review and Investigations Committee

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PRI Committee• Oversight committee of Connecticut General Assembly

• Uniquely bi-partisan - 6 Democrats, 6 Republicans, and equal members from Senate and House

• 2 co-chairs – one from each party and chamber – rotates every 2 years

• Staff of non-partisan analysts

• This study topic chosen by committee after discussions with leaders of Appropriations and Human Services

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Study Focus• Examine use of Emergency Departments (EDs) by

Medicaid Clients:

• Utilization and costs of ED care for Medicaid clients and impact on Medicaid budget

• Frequent use of ED by Medicaid clients and strategies to prevent or divert clients

• Access to health care for HUSKY clients compared to individuals with other types of insurance

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Study Challenges• Complex system with many entities involved

• Several initiatives to better coordinate health care – all at different stages of planning or implementation

• Availability of Medicaid data were limited since ED data not routinely run by DSS

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Study Methods• Interviews with state agencies, ASOs, other interested parties

• Visits to several hospital EDs and discussions with ED physicians

• Analysis of Medicaid client claim data provided by CHN

• FQHC visits and interviews

• Surveys of hospital EDs and FQHCs

• MAPOC website materials

• Review of literature

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Study Milestones in Brief• Committee approved Scope of Study -- June 2013

• Staff presented initial information and findings to committee in September 2013

• Committee held an informational public hearing in September

• Meeting to discuss Findings and Recommendations January 31, 2014 – approved report - Findings and Recommendations

• Raised a bill RB 5378 – held 2 community public hearing on bill

• Incorporated many changes and approved yesterday

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Presentation Areas• Overview of ED Utilization in Connecticut

• Medicaid Utilization and Costs

• Access to Care for Medicaid Clients

• Intensive Case Management

• Controlled prescription drugs and ED visits

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Federal Emergency Medical Treatment & Labor Act (EMTALA)

• Signed into law in 1986

• Ensures public access to emergency services regardless of ability to pay

• Three basic obligations under EMTALA

• Any individual who comes and requests examination or treatment of a medical condition must receive a medical screening examination by a qualified medical provider to determine whether an emergency medical condition exists.

• If an emergency medical condition exists, treatment must be provided until it is resolved or stabilized. If the hospital does not have the capability to stabilize the emergency medical condition, an "appropriate" transfer to another hospital must be done in accordance with the EMTALA provisions.

• Hospitals with specialized capabilities must accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.

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2008 2009 2010 2011 20120

200,000400,000600,000800,000

1,000,0001,200,0001,400,0001,600,0001,800,0002,000,000

1,586,179 1,650,050 1,674,123 1,705,506 1,760,527

Total ED Visits to CT Hospitals: FFY (includes those leading to inpatient admission)

Source: Department of Public Health (DPH) Office of Health Care Access (OHCA)

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2008 2009 2010 2011 20120

200,000400,000600,000800,000

1,000,0001,200,0001,400,0001,600,0001,800,0002,000,000

Total ED Visits: FFY

Treated and Admitted Treated and DischargedSource: DPH Office of Health Care Access

• Most people visiting an ED are treated and discharged – about 85 percent of all visits

• For all ED visits, about 15 percent of individuals were admitted to inpatient

• Only about 7 percent of ED visits by Medicaid clients resulted in an inpatient admission

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793,60645%

619,31035%

297,02417%

Figure I-6. Timing of ED Visits to Connecticut Hospitals: FY 2012(including those leading to an inpatient admission)

(N = 1,709,940)

9:00 a.m. - 4:59 p.m.

5:00 p.m. - 11:59 p.m.

Midnight - 8:59 a.m.

Source: DPH, OHCA

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• Medicaid clients had the greatest percentage of ED visits (36%) but only represent 16.5% of Connecticut’s population

• ED Visits by people with commercial insurance accounted for about 31% of total visits even though they represent about 52 percent of Connecticut’s population

Medicaid36%

Commercial31%

Medicare22%

Uninsured10%

Other Public1%

Figure I-7. ED Visits by Payer Source: FY 2012 (including those leading to an

inpatient admission)

MedicaidCommercialMedicareUninsuredOther Public

Source: DPH, OHCA

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Table I-1. Utilization Trend in Connecticut: Rate per 100 Payer Population by Payer Source

(treated and discharged from the ED)

Payer Source 2010 2011 2012Commercial 18.5 18.1 18.5Medicaid 116.4 112.7 106.8Medicare 45.3 44.2 46.3Self-Pay 37.5 45.8 49.0Sources: DPH, OHCA: Individual Hospital Annual Report Filings: Report 165 – Hospital Gross Revenue, Net Revenue and Statistics by Payer Source (2011 and 2012), and U.S. Census Bureau, Health Insurance Historical Tables, HIB – Series, All Persons 1999-2012.

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Table I-2. Medicaid Programs by Eligible Populations 

Program 

DescriptionTotal Enrollment for

CY 12Total ED

VisitsVisits per 100

Clients

 HUSKY A

Eligible children, parents, relative caregivers, elders, individuals with disabilities, low-income adults, and pregnant women

 423,484

 369,992

 87

 HUSKY B

Non-entitlement State Children’s Health Program (SCHIP) for children under age 19 – copays and/or monthly premiums

 13,965

 6,068

 44

 HUSKY C

Available for low-income Aged, Blind and Disabled Connecticut residents who are aged 65 or older, blind or have a disability. Many are also eligible for Medicare

 95,920

 71,173

 74

 HUSKY D

Low-income individuals aged 19 through 64, who do not receive federal Supplemental Security Income or Medicare (used to be State Administered General Assistance (SAGA) program)

 86,086

 158,273

 184

TOTAL 619,455 605,506 97Source: DSS information provided to PRI staff.

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ED Cost/Use by Medicaid Recipients (No Inpatient Admission): CY 12

• 267,700 Medicaid clients visited an ED

• There were 605,506 visits by these clients

• Medicaid reimbursements was slightly more than $229 million

• Average cost per ED visit - $350

• Average cost per ED patient - $791

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Finding• ED visits by Medicaid clients are not a major cost driver of

the overall Medicaid budget

• Higher rates of ED utilization by Medicaid clients compared to the rest of the population suggest better access to community health care could improve health outcomes

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Recommendation (#1)The Department of Social Services should:

• develop brochures about alternatives available to the emergency department if a client does not need immediate attention.

• The brochures should be made available to clients at federally qualified health centers and primary care offices with high Medicaid patient caseloads.

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Husky A Husky B Husky C Husky D0

0.5

1

1.5

2

2.5

3

3.5

2.01

1.49

3.3

2.72

Figure I-12. Average Number of ED Visits Per Member by Husky Program: CY 12

Avg

. Visi

ts

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HUSKY A HUSKY B HUSKY C HUSKY D$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$307 $295

$460$403

$617

$439

$1,518

$1,094

Figure 1-11. Costs by HUSKY ProgramPer Visit and Per Client: CY 12

(excluding ambulance costs)

Per-Visit Cost Per-Client Cost

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Reasons for Frequent Use of ED• Acute medical conditions

• Chronic medical conditions

• Need access to specialists

• Behavioral health• mental health• alcohol• drug-seeking behavior

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• ED usage patterns show about 52% of the 267,700 Medicaid clients who had an ED visit in CY 12, visited only once

• About 8% of the 605,506 ED visits in CY 12 had a primary diagnosis of behavioral health, including 2% as alcohol-related

• There is no commonly accepted definition of a frequent ED user, but 4,671 clients had 10 or more visits to an ED in CY 12

1 visits 2-3 visits 4-6 visits 7-9 visits 10-14 visits

15-19 visits

20-49 visits

50-99 visits

100+ vis-its

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000140,169

89,100

28,675

6,590 2,939 867 767 85 13

Figure I-13. ED Users -Frequency of Visits: CY 12

Num

ber

of C

lient

s

Source: DSS

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1 2 3 4 5 6 7 8 9 >100

50

100

150

200

250

129

238

180

122

77

43

2418

1024

Figure I-14. Number of Different EDs Visited by Medicaid Clients with 20 or more ED Visits in CY 12

Number of Different EDs Visited

Num

ber

of C

lient

s

Source: DSS

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Recommendation (#2)• The Department of Social Services should report annual ED

use by Medicaid clients including:

• a breakout of the number of unduplicated clients visiting an emergency department

• clients with 10 or more annual visits to any ED

• The department should use this information to monitor contractor performance, particularly with linking frequent users of emergency departments to primary care providers following an ED visit.

• The report should be provided to the Council on Medical Assistance Oversight

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Presentation Areas• Overview of ED Utilization in Connecticut

• Medicaid Utilization and Costs

• Access to Care for Medicaid Clients

• Intensive Case Management

• Behavioral Health, Substance Abuse and ED visits

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Medicaid Access• Most other states cover Medicaid population through managed care organizational model

• Capitated rate from state to MCO to cover members• MCO takes financial risk

• Connecticut used MCO model for HUSKY A and B until 2012

• Abandoned the model because of legal issues and questions about rates and adequate coverage

• HUSKY C and SAGA clients had always been Fee-for-Service

• Now all populations are covered under an Administrative Services Organization model (hybrid)

• State assumes financial risk – Medicaid ASOs to assist with aspects of care

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Administrative Services Organization• Roles and Responsibilities:

• Member and provider services• Referral assistance and appointment scheduling• Provider recruitment• Health education• Utilization management • Case management including intensive case management• Quality management• Health data analytics and reporting

• Not responsible to pay claims

Source: DSS Presentation to Appropriations Subcommittee, February, 2012

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Alternatives to Hospital ED• Medicaid population biggest user by payer source• Hospital Emergency Department use by people with

private insurance has dropped For privately insured clients:• co-pays for ED use – avg. about $75 up to $150 • Many urgent care centers, located in suburbs, with

low co-pays ($20 -$30)• Minute clinics• Promotion of preventive and primary care through

lower insurance premiums, etc.

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Alternatives To Hospital ED: Medicaid• Many of the options are not available or not easily

implemented with Medicaid

• Co-pays authorized in 2013 session – not implemented yet

• National studies indicate co-pays not effective tool

• Clients need assurances that other alternatives exist

• Better education of clients about alternatives and benefits of using them vs. ED

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Alternatives to ED• Ample supply of primary care providers

• CT ranks high in supply of physicians and other primary care for overall population

• But access for Medicaid clients not the same • Rates have historically been much lower

• Access to primary care will be important as Medicaid expands under the ACA

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Medicaid: Measuring Access

• Administrative Services Organizations measure access

• Measured by Geo Access shows very high percentage of Medicaid clients have access

• Limitations

• Does not measure providers not accepting new Medicaid clients• Length of time for an appointment• Access to urgent care

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Medicaid: Measuring Access• Another measure that ASOs use is mystery shopper survey

• Would reveal those issues about appointment time, etc.• Required by contract to produce this annually – not been done in a while

• Will become even more important when providers are paid enhancements to manage and coordinate care

Recommendation # 3DSS require ASOs to annually conduct mystery shopper survey and report results as required

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Medicaid Access

• Network of primary care providers enrolled in Medicaid has increased• Physicians from 1,362 to 2,441• Physician assistants and APRNs – from 260 to 777

• Much of expansion result of rate increases under ACA• Primary care Medicaid services reimbursed at

Medicare rates• Some rates almost doubled -- $67 to $123• Fully federal reimbursement for 2 years

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Medicaid Access: Attribution• Another ASO responsibility is to “attribute” or link patients to

a primary care provider

• Clients can choose or ASO “attributes” based on claims data

• Overall rate of about 64 percent

• Approximately 80 percent of children have been linked to a primary care provider, but only about 50 percent of adults

• Even lower for attribution to patient-centered medical homes

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Medicaid Attribution• Low attribution rate indicates people are not getting primary

care• ASOs need to take a more assertive approach

Recommendations # 4 and # 5• At earliest stages -- when a client enrolls in Medicaid -- ASO

should contact about primary care providers in area• Promote advantages of being in a Patient-Centered Medical Home• Work with client to make appointment

• Primary care provider and contact information on enrollee’s Medicaid card

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Medicaid Access: Continuous Eligibility

• Another deterrent to accepting a Medicaid client is uncertainty of eligibility

• Important to achieve predictability and stability in Medicaid eligibility as expansion occurs

• To help with access and continuity of care• National studies show average per member monthly

costs are less longer a person is covered• Limit provider risk in getting reimbursed

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• Federal Medicaid agency suggests a number of strategies to help states with Medicaid expansion

• Continuous eligibility is one CMS-suggested strategy• CT had continuous eligibility for children until 2003• Connecticut could resume for children unilaterally• Need to seek an amendment to waiver for adults

Recommendation # 6Legislature adopt 12-month continuous eligibility for children and DSS seek a approval from CMS for continuous eligibility for adults

Medicaid Access: Continuous Eligibility

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Medicaid: Access to Specialists• Cited as persistent problem in Medicaid• Low reimbursement rates – less than 80% of Medicare rates

• Specialist rates not subject to boost under ACA• Primary care providers and FQHCs spend many hours trying to get specialist appointments – often have very long waits

• Need to develop other strategies to improve access

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Medicaid: Access to Specialists• Many other states are authorizing some Medicaid services be provided by • telemedicine or telehealth• rather than face-to-face• CMS allows for Medicaid reimbursement

• One of the FQHCs has developed an initiative with specialists at UCHC for telehealth

• These efforts would increase access to specialists

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Medicaid: Access to Specialists• DSS statutorily authorized to develop a demonstration

project with a FQHC to develop telemedicine initiative

• DSS not done that yet – analyzing with UCHC –results in March

Recommendation # 7 Require DSS to engage in a demonstration project using telemedicine or telehealth and report on results and possible expansion to human services and appropriations committees

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Medicaid: Overall • CHNCT reported mostly positive overall outcomes for all

Medicaid clients with ASO model:

• Inpatient admissions declined by 3.2%

• Inpatient days decreased by 8.1%

• Average inpatient stay ↓ from 5.4 days to 5.1 days

• Cost of inpatient stay ↓ from $7,545 to $7,345

• ED visits declined 3.2% but costs increased 8.5%

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Medicaid: Intensive Case Management

• Another responsibility of various ASOs

• Which ASO and type of case management depends on Medicaid population and services needed

• Examined the ICM services by CHNCT, ValueOptions, Advanced Behavioral Health, and one by Middlesex Hospital

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Medicaid Intensive Case Management

• CHNCT conducts ICM primarily for chronic medical conditions

• Higher priority of clients with inpatient admissions• Clients are not required to participate• CHNCT engages about 40 percent of members identified

• Outcomes 6 months pre and 6 months post ICM 1/1/12 and 10/1/12• 43% decrease in inpatient admissions• 6% reduction in ED visits

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Medicaid: Intensive Case Management• ValueOptions – Primarily behavioral health ASO• Coordinates with CHNCT for those clients with dual

diagnosis

• In 2011 PA report on ED use by 41,049 adult clients with BH showed;

• 12% had readmits to ED within 7 days• 28% had readmits to Ed within 30 days• almost 38% showed no indication of follow-up outpatient after ED

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Medicaid: Intensive Case Management• Provider Analysis report on ED use has not been

produced since 2011 so unknown whether there has been improvement in this area

• This report is one that is contractually required

Recommendation # 8 Require DSS to better monitor the ASOs’ reporting requirements to ensure the agency is getting all contractually obligated reports, including the Provider Analysis report on ED use

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Medicaid: Intensive Case Management• Report includes description of several intensive case

management programs, including outcomes (pages 40 - 47)

• Intensive case management services of the two major ASO have been Medicaid reimbursable but not those of ABH

Recommendation # 9 DMHAS work with DSS and OPM to ensure that all expenditures for all eligible intensive case management services are submitted for Medicaid reimbursement

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Intensive Case Management• ABH-reported outcomes for 2-year period:

• 57% reduction in inpatient episodes• 46% reduction in costs• 18 percent decrease in ED visits• 21% cost savings

• Middlesex Hospital Community Care Team Model• 59% reduction in inpatient admissions• 51% fewer ED visits • $9,329 decrease in per client hospital costs (65%↓)

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Medicaid: Intensive Case Management

• Factors associated with more positive outcomes of the various ICM programs, especially with frequent ED users:• More face-to-face contact with clients• ED knowledge and awareness of the program• ED involvement in selection of clients for ICM• ED involvement in development of care plans• ongoing (not episodic) ICM monitoring of client’s progress• frequent meetings of community providers involved in care• persistence in engaging clients and in managing care and

needs

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Medicaid: Intensive Case Management• These are factors associated with the Middlesex Hospital

Community Care Team model, which showed favorable results, and should be replicated to improve outcomes, especially with frequent users of the ED

Recommendation # 10DSS and DMHAS should contractually require ICM teams to identify hospitals for CCT program based on frequent ED use and work with hospital EDs to identify clients who would benefit from CCT approach

Co-locate at least one ICM staff at hospital EDs that participate at hours when ED use is highest

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Medicaid: Intensive Case Management• Recommendation # 11

Requires these ICM staff to:

• work with participating ED doctors to develop a care plan for clients who participate

• have knowledge of area community services and providers• serve as liaisons between hospital ED staff and providers• meet with providers weekly to monitor progress

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Other Community Programs• Report describes (pp. 48-50) programs aimed at helping

with substance abuse recovery and supportive housing

• Examples of providers/programs that Intensive Case Managers should work with in helping the clients in community care team approach

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Controlled Prescription Drugs and ED• Nationwide problem and not limited to Medicaid

• Patients seeking controlled prescription drugs like OxyContin for pain or diversion

• No hard data exists on extent but ED doctors and others state it is a problem

• 7 of the 11 FQHCs indicate they have a policy for prescribing narcotics and 2 more are developing

• Policy typically requires patient to sign a contract

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Controlled Prescription Drugs and ED• Patients seeking these CPDs may visit the ED because of belief it will be easier to get a prescription there

• Because they may be limited by other provider

• ED doctors can check the state’s prescription drug monitoring program

• ED doctors cite issues around ease of access to information

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Controlled Prescription Drugs and ED• ACEP has developed guidelines for prescribing these drugs in ED,

which includes checking the prescription drug monitoring program

• Other jurisdictions like NYC have imposed greater restrictions on ED prescribing

• But before issuing such strict measures that limit an ED doctor’s professional judgment

Recommendation # 12ACEP guidelines, which include checking the prescription drug monitoring program, should be followed before prescribing controlled prescription drugs in ED

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Controlled Prescription Drugs

• Extent of problem in Medicaid program unclear

• But CMS issued a brief in 2012 suggesting strategies to states to deal with the issue in the Medicaid program

• DSS Office of Quality Assurance also has access to prescription drug monitoring program – not sure about extent it is used to monitor and flag Medicaid client behavior

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Controlled Prescription Drugs

• To help address the issue in the Medicaid population

Recommendation # 13 • the CMS strategies bulletin be circulated to appropriate DSS

staff • the DSS Office of Quality Assurance identify Medicaid clients

who are outliers on prescription drug monitoring program and refer clients to determine if they should be placed on pharmacy restriction

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Summary

• Most of the recommendations are contained in RBs 5378

• Approved by PRI committee March 13, 2014

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HOSPITAL EMERGENCY DEPARTMENT USE AND ITS IMPACT ON THE STATE MEDICAID BUDGET

for full report and other study materials see:www.cga.ct.gov/pri/index.asp