While studies find conflicting evidence about role of Medicaid expansion on ED use, plans and providers are identifying barriers to care and reducing ED visits.

Oct. 26—Emergency department (ED) visits rose by 40 percent per beneficiary in the first 15 months after gaining Medicaid coverage through an Oregon random selection process, a high-profile study found.

In the recent New England Journal of Medicine study, the authors found “newly insured people will most likely use more healthcare across settings--including the ED and the hospital--for at least two years and that expanded coverage is unlikely to drive a substantial substitution of office visits for ED use.”

The study poses challenges for policymakers and state Medicaid agencies hoping to control rising healthcare costs and rein in state budgets as more states consider expanding their programs under Obamacare.

Matt Salo, executive director of the National Association of Medicaid Directors, said “greater than predicted use” doesn’t necessarily connote a problem.

“We should expect a lot of ED use because there has been an enormous amount of pent up need for healthcare services,” Salo said in an interview. “Most of these beneficiaries were not getting any health care because they were uninsured. It’s actually legitimate to see a spike. But we should also see a decrease as unchecked chronic conditions are treated by physicians.”

The issue is complex, Salo said.

“Rather than penalizing what you don’t want, figure out how you can incentivize the behavior you do want,” Salo said.

Many newly covered beneficiaries have chronic conditions or poorer health requiring more services and the ED is the most convenient place to go for care, Clif Gaus, president and CEO of the National Association of Accountable Care Organization, said.

An increase in ED visits may not in itself be a cause for alarm.

 “Ultimately, what we need to know, but the Oregon experiment has yet to show, is whether this increase in utilization is appropriate and leading to better long-term outcomes or just over-utilized care because it is free,” Gaus said in emailed comments.

Anna Hwang, MD, director of Community Catalyst’s Center for Consumer Engagement in Health Innovation, said the evidence on ED utilization for newly enrolled Obamacare Medicaid expansion beneficiaries is conflicting. Hwang said that some reputable studies have found higher than expected ED use among this population, while others have concluded otherwise.

A 2013 medical literature review in the American Journal of Managed Care found 37 percent of all ED visits were judged to be non-urgent.

A 2016 Health Affairs study found that Medicaid expansion did not increase ED use.

Why ED Used

It’s important to think of the reasons why this population accesses ED care and target solutions, Hwang said in an interview.

 “There are some really interesting models where people have been able to coordinate care and decrease ED utilization,” Hwang said. “But ED utilization is only a piece of puzzle.”

For instance, Hennepin Health, a Hennepin County (Minnesota) Medical Center Medicaid ACO model, has achieved “impressive results with enrollees with high ED utilization, in some cases by supplying housing” and providing care coordination for high risk members, Hwang said. In a case study, Hennepin Health cut ED visits by 9.1 percent from 2012 to 2013, while outpatient visits increased by 3.3 percent. 

Jeff Myers, president and CEO of the Medicaid Health Plans of America (MHPA), said ED overutilization a “big issue” for his member plans, which serve more than 20 million Medicaid enrollees.

“Plans are taking these challenges seriously,” said Myers. “Ultimately, ED visits don’t drive quality of care, because most of these enrollees have chronic conditions that are served better in less intensive and less costly care settings.”

Addressing the Challenge

MHPA plans are employing innovative ideas to drive better quality at lower costs.

While California saw spikes in ED use by Medicaid enrollees after Medicaid expansion there, according to a state report, Myers attributed some of that rise to a California-specific regulation controlling the use of non-emergency medical transportation.

“Enrollees without access to a car would use the ED and call ambulances like taxis,” Myers said. After the state removed some restrictions, California’s ED utilization dropped, according to Myers.

Medicaid managed care plans also employ financial incentives to drive down ED use. Myers cited a significant Indiana decrease in ED utilization after its Healthy Indiana Plan instituted financial disincentives for visiting the ED for non-emergency reasons.

Margaret Brodie, director of Health Care Services for Alaska’s Department of Health and Social Services, said her state’s Medicaid program examined claims data to identify individuals using the ED five or more times in an 18-month period. Through data gleaned from the Alaska Medicaid Coordinated Care Initiative, Brodie’s staff mapped out recipient addresses and found the majority lived in the same Anchorage neighborhood from where a health clinic had recently relocated.

“So we worked with the nearest hospitals and provider associations and were able to get a hospital to open up a clinic there,” Brodie said in an interview.

Three percent of Alaska Medicaid beneficiaries account for more than 22 percent of all ED expenses, Brodie said.

The state hired MedExpert to manage the healthcare needs of the “super-utilizers,” not just those from the neighborhood, but statewide.

“In the first two years of the program we’ve seen a 20 to 25 percent reduction in ED visits and a 20 percent reduction in spending on ED services,” Brodie said.

A Medicaid managed care plan saw decreased ED utilization after physicians there focused attention on members with substance and addiction issues. In 2014, UPMC had a dramatic increase in ED visits related to opioid use, said Nicholas DeGregorio, MD, senior director for the University of Pittsburgh’s UPMC for You. The health plan’s High-Emergency Department Drug Seeking Utilization Protocol program identified “super-utilizers” whose common trait was opioid use and learned these members viewed the ED as a way to obtain opioid prescriptions.

“We developed this program around the highest risk members and did intensive care outreach,” DeGregorio said. “We also reached out to prescribing providers to determine who might genuinely need pain management and who was at risk of a drug overdose or death.”

Enrollees reviewed by care managers in 2015 to 2016 saw a 30 percent reduction in ED utilization, DeGregorio said.

Inappropriate ED use poses a long term challenge for health plans, Myers of MHPA said.

“Over time we are seeing some downward revision in ED use,” Myers said. “What we do know is overall these coordinated care plan designs are much better than the alternatives: unmanaged access or no insurance at all.” 

 Mark Taylor is a freelance writer based in Chicago.


Publication Date: Wednesday, October 26, 2016