ER is for Emergencies

Shrinking budgets are a common problem for emergency services providers. While it’s far from ideal to take resources away from healthcare providers who are in the business of saving lives, some creative solutions have emerged to combat the budget cuts that plague us all.

Take Washington state for example. About three years ago state lawmakers, facing a budget crunch, approached the state Health Care Authority and state Department of Health with instructions to cut about $32 million from their budget, according to Stephen Anderson, MD, a past president of the Washington Chapter of American College of Emergency Physicians (WA-ACEP).

“So they came up with the idea of doing that by restricting access to the emergency department, by saying if you were on Medicaid you could only go to the emergency department three times a year,” Anderson explains. “Trust me, there were bureaucrats who didn’t understand why people who are in the loop would actually laugh when they hear that. Not only is there the 1996 Health Insurance Portability and Accountability Act (HIPAA) that says a prudent layperson always has the right to go to an ED, but it just doesn’t make any sense—turning away the most vulnerable, the most at risk. They came up with a list of what they thought were non-emergent diagnoses, and the diagnoses included things like chest pain, sudden loss of vision, hemorrhage with miscarriage, etc.”

Anderson says the WA-ACEP responded immediately to tell policymakers why this plan wouldn’t work. With the help of groups like the Washington State Hospital Association, Washington State Medical Association, American Heart Association and American Stroke Association, WA-ACEP approached the state—via the media and even the court system—to say not only wouldn’t the plan work, but it’s bad policy.

“All of a sudden a couple of level heads just said wait, stop, what we all want to do is practice sound healthcare, we want to save money, we want to do it practically because we recognize there just isn’t money here for the state, so why don’t we put our heads together and come up with a better system that doesn’t restrict access, but what it really does is help coordinate the care of the highest utilizers, which are also the ones the most at risk,” says Anderson.

What emerged was the Seven Best Practices program, and it’s changed the way Washington treats its most at-risk patients.

Those best practices are:

1. Tracking frequent users of emergency departments and adopting electronic tracking systems to exchange patient information.
2. Disseminating patient educational materials about appropriate settings for healthcare services, which are provided at arrival or discharge.
3. Designating personnel and emergency physician personnel to receive and appropriately disseminate information on Medicaid clients.
4. Contacting primary care providers at the time of the emergency visit and relaying any issues regarding barriers to primary care.
5. Implementing narcotic guidelines that direct patients to primary care or pain management services.
6. Enrolling physicians in the state’s Prescription Monitoring Program.
7. Designating emergency physician and hospital staff to review and provide feedback reports, and taking appropriate action.

“The real key was the first one, to actually create an infrastructure of an electronic health information exchange that would let us all know right when anybody checked into an emergency department if they had been in an emergency department more than five times in the last year,” Anderson says. “Because if they had, that kind of signaled to us they were higher utilizers. It frequently ended up meaning they had drug, alcohol and/or psychiatric issues, but it also meant they had cardiac issues, dialysis issues, those types of things. And we just knew if we were able to coordinate the care of those patients, we’d easily save the state more money than just by telling people not to come to the ED.”

So now the highest utilizers of the ED system are identified right when they get to the ED and put into a “Patients Requiring Coordination” (PRC) group. The Medicaid system puts together a plan for those patients, both to coordinate a care plan so if they are going to one hospital particularly often they’ll get assigned to that hospital, and to create a care plan at that hospital and share it will all the other hospitals. The kind of information shared, explains Anderson, can be as simple as “don’t re-CAT scan this person for their 20^th visit for abdominal pain” but by relaying it between healthcare providers and physicians to prevent redundancy, a lot of time and money can be saved.

As part of the Seven Best Practices, Washington also joined the majority of other states by creating a prescription monitoring program, which allows for sharing narcotic prescription information across all providers.

The educational component of the Seven Best Practices includes patient handouts, but according to Anderson the most controversial thing they did in Washington was put up posters in every single emergency department in the state of Washington, and in every exam room. Those posters have since been adopted in about 28 other states, but recently there has been a request to remove them from the triage area because of the perception they might dissuade people from logging in, Anderson explains. “The intent of the poster was not to tell people to ‘leave the emergency department, you’re not going to get narcotics here,’ the intent of the poster was to try to educate people that the No. 1 cause of accidental death in America is overdose from opiate prescriptions,” he says. “And we were really trying to educate the community that we had this system in place that was trying to coordinate narcotic prescriptions. So by doing that we were able to also decrease the number of people who came to the emergency departments because the goal was to try to get the right people to the right place at the right time. And part of that was for chronic pain we were trying to get that out of the emergency department and back to the primary care doctor.”

Once these high utilizer patients are tied back into a primary care doctor, every ED director in the state gets reports so they can see both how their department is doing and how individual physicians are doing as far as things like identifying patients requiring coordination, trying to decrease the number of narcotic prescriptions going out to high utilizers, and trying to decrease x-ray and radiation exposure for the same patients.

In Anderson’s opinion the whole thing has been a win-win-win-win for everyone involved. “The docs love it, because of the addition of more tools to help coordinate these patients. It’s something they can actually use to would help take care of these people,” he explains. “The patients actually like it because you know something about them and the vast majority of them don’t resent that. Its like, ‘Oh, you know I already had a CAT scan, what did it show?’ And you can tell them and you won’t have to do it again. And the patients get tied into a primary care doctor so we could feed them back to somebody they didn’t even know they may have had.

“The hospitals love it because while the hospitals actually had some up-front money to create some of the electronic infrastructure, they ended up saving money because a lot of the patients were not high reimbursement patients. And then the bottom line was the state started the whole thing and in the end the state saw about a 10% decrease across the board in all Medicaid patients, about a 24% decrease across the board in ER visits for the PRC sub-group, and they ended up saving about $33 million, even more than they would’ve with “just say no.” That first round of numbers is from about 8 months ago and we’re coming up on another round of numbers and it looks like we’re going to save at least that much again.”

The Seven Best Practices have proven so effective Anderson has started fielding calls from other states asking how they can do something similar. The easiest way is to read up on everything Washington did on Washington ACEP’s website, washingtonacep.org. Anderson also points interested parties to Collective Medical Technologies, the Utah company that helped design the state’s electronic information exchange.