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State Tries New Tack To Cut ER Visits By Medicaid Patients

Ruby de Luna

Since last September, Washington hospitals and emergency room physicians have been at odds with the state. The center of their dispute: how to cut costs from ER overuse by Medicaid patients. Medicaid is a federal–state program for people without insurance. In the past year, four out of 10 Medicaid clients went to the ER.

Recently both sides reached a compromise. For now, ER doctors will try to address the problem their way. And if it doesn't work, the state will impose a bigger change.


One of the changes coming to ERs will sound like this:

Anderson: "I think you have a drug or alcohol problem."

This is from a presentation at a recent conference for doctors in emergency medicine. Stephen Anderson is an ER doctor at Auburn Regional Medical Center. He's giving his colleagues some pointers on how to manage difficult conversations. For example, how to have a talk with a patient who comes to the ER too frequently to get a prescription for narcotics.

Anderson: "It's our job, whether we like it or not. And what we do know from countless research is that this is the pivotal time to have this conversation."

Dr. Anderson says it's a pivotal time for patients because they're likely to listen. It's a critical time for doctors and hospitals, too. The state has been putting pressure on them to cut back on unnecessary visits because they're costing millions of dollars. And everybody agrees, it's not the best way to get care.

Anderson: "Every aspect of medical care has some amount of money that we could trim, and the emergency department is not an exception."

Washington state has tried other approaches before. Officials initially put a cap on the number of unnecessary ER visits they'll pay for, but that backfired. Doctors and hospitals say it forces people to self–diagnose. They sued and won. The state then came up with a new policy. It would stop paying altogether for treatments in the ER that were considered non–critical.

In April, both sides made a deal. The doctors came up with a set of requirements that they hope will lower the number of ER visits without compromising care.

Anderson: "The visit to the emergency department may not be nearly as expensive as the work–up that happens. So if you just come in and say, my ear hurts, and I give you a prescription for Amoxicillin, and you go out the door, that's not the big expense. It's when you come in and say I have abdominal pain, and you need a CT scan, and blood tests, and all these other work–ups."

The latest agreement hinges on doctors and hospitals using online tools. One of those tools is the Emergency Department Information Exchange. It's an online program that allows doctors to access patients' electronic medical information no matter where they've been. And that allows doctors to look deeper into the patient's medical history. Anderson says this helps avoid duplicate tests.

Anderson: "So I can say to patient, wait, you were just in Puyallup last week, and what did they do there? Did they do CT scan? Yes, well, why don't I get that CT scan report and look at it before I order another CT scan here."

Another tool is the state's prescription monitoring program. The online database keeps records of patients who've been prescribed narcotics.

By the end of the year, hospitals and emergency physicians must sign up with both of these online programs. That way, the state can monitor changes.

Thompson: "Now the trick will be is getting everybody to use it."

Dr. Jeff Thompson is chief medical officer of the state's Health Care Authority, the agency that runs the Medicaid program.

Thompson: "You can sign up, but if you don't use it, it's not effective."

Thompson says so far, everybody is making an effort to change the current trend. But he'll also be checking if the doctors' and hospitals' plan is making a dent.

Thompson: "We'll look at utilization rates of emergency rooms and hopefully that will go down for non–emergent conditions. We will look at total costs of emergency room care, we'll look at the number of narcotics coming out of emergency rooms — all those things will be in the feedback reports."

In addition to making internal changes, the medical community is reaching out to the public. Hospitals now post signs and brochures in waiting rooms to remind people that emergency rooms are exactly that, they're for people with medical problems that are life threatening.

And remember those difficult conversations that doctors will be having with some patients? The state is sending letters out to doctors with advice on how to talk to patients about their ER use. The idea is to get to the root cause of what's bringing patients to the ER, and to see if there's a better way to address their medical problems. That's the hope. And if hospitals don't meet those goals, Medicaid payments are likely to fall.

I'm Ruby de Luna, KUOW News.

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