Crash Cart: Reducing ED Super Utilizers and Medicaid capping ER emergencies

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REAL PHYSICIANS DISCUSS RECENT HEALTHCARE HEADLINES

Below is an excerpt from the full conversation, which is available on epmonthly.com. Have a story you want discussed? Sound off @epmonthly or email editor@epmonthly.com.

Reducing ED “Super Utilizers”

Thanks to a new partnership, Regional One Health has seen encouraging results in reducing emergency room super users who average 85 hospital visits annually. Regional One identifies why visitors are coming so frequently to reduce ED costs and send the super users to more appropriate resources.


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Seth Trueger, MD MPH FACEP

It’s always great when EDs try to take good, positive steps to address superusers. There are a couple different reasons some patients are in the ED a lot, particularly homelessness, and figuring out steps such as housing and shelter resources can help make positive strides. I’ve seen some interesting results in the past, especially based on how high utilization is defined (eg 10 ER visits per year). For many patients, being a “superuser” is temporary, eg they are getting treatment for cancer and have a variety of complications; it’s not all homelessness. The most important part is making sure patients are getting access to other resources more suited to their needs, not pushing people away when they have no other options.  Which brings me to…

We’ve been through this before. “Capping reimbursement for non-emergency visits to hospital emergency rooms” sounds good in theory but patients can’t tell which symptoms are emergencies or not. Heck, we often can’t, particularly without seeing the patient first (and even then…).


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And frankly, that’s just not where the money is. I have a bunch of references on this here and in the March 2018 EPM re: Anthem’s attempt to do the same. Policies that attempt to identify which patients didn’t need to be in the ER for “non-emergency visits” punish patients who don’t have other options, can’t tell what is or is not an emergency, and punishes ERs for treating them.

Most of the homeless patients with mental health problems etc will die decades before any of us do. About 6 of our superusers died my last year of residency — all of them younger than I am now.

Nicholas Genes, MD, PhD

This is another aspect of modern healthcare that my mother will just never accept. One patient had 195 ED visits in a year? More than once every two days? EMS kept transporting this person? Triage kept triaging? The doctors kept seeing this patient? “Well, mom, many state laws require EMS to transport, and when they get to the hospital, there’s EMTALA, and you never know — a lot of these patients do have medical problems, and this could be the time they’re really sick…”


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She’d frown, shake her head, and lament the lack of common sense, both in the way the rules are written, and our rigid, unthinking enforcement of them. There are bigger problems in healthcare spending, no doubt, but it’s nonetheless disheartening that we haven’t implemented, or even developed, kind of policy to deal with these cases. Super-users suck the souls of healthcare staff and are easy, distracting targets for those who’d prefer not to discuss (or explain) the waste and expense elsewhere in healthcare.

Look at PBMs or the Chargemaster. Deep, confusing problems, and much more expensive than ED super-users…but we’re not talking about them, are we? To paraphrase Aaron Sorkin, superusers don’t cost money — they cost votes. They costs airtime and column inches. Let’s fix this, so the next Crash Cart can be devoted to the bigger, more complex problems in healthcare.

Paul DeKoning, MD, MS

I’m continually amazed at the sundry things that actually make patients superusers. Homelessness and financial concerns are certainly real. And we have those here, but other issues we (perhaps more) frequently encounter include fragile mental illness, chronic pain and non-compliance. It can be challenging to care for these patients and it’s frankly pretty dangerous for them — it’s easy for things to get overlooked simply because they’re back again for the fourth time this week.

That’s where M&Ms live. And not the kind you eat. We have established multi-specialty care plans for some of these individuals which have actually helped to avoid big misses and has in many ways served to make these encounters far less confrontational.

William Sullivan, DO, JD

We can debate what constitutes a superuser and what societal ills are associated with being a superuser, but those topics are tangential to the real issue: Once we’ve identified “causes” of ED overuse, how do we reduce inappropriate use of the emergency department? If patients repeatedly come to the emergency department because they are homeless, how do we address that issue? Find them a shelter? Great. What if, as in many such patients I’ve seen, they’ve been kicked out of shelters for failing to follow the rules?

Maybe the patients are mentally ill. What if, as in many cases, they don’t show up to outpatient psychiatric appointments (or there aren’t any timely appointments available)? Do we force them to undergo inpatient treatment? If so, what if they continue inappropriate emergency department use after discharge? How do we manage patients who refuse to take their medications? What about patients who repeatedly miss dialysis treatments because those treatments were inconvenient for them?

I don’t have the answers, but when I work in an emergency department and a patient has visited the emergency department more times than I have in a year, we have to stop justifying those actions by saying “well he *might* have a *real* problem *this* time.” Right now, we’re in the “insanity” loop of doing the same thing over and over again and expecting different results. And Nick is right that some patients who abuse the ED suck the souls from the staff. With the morale of emergency medical staff hovering somewhere below the floorboards of the toilet right now, that is precisely the reason we should take this issue more seriously.

Medicaid cap should help keep ER services for emergencies

A New Jersey law caps Medicaid ER visits at $140 for non-emergencies in an effort to discourage inappropriate emergency room use.

Seth Trueger, MD MPH FACEP

We’ve been through this before. “Capping reimbursement for non-emergency visits to hospital emergency rooms” sounds good in theory but: a) patients can’t tell which symptoms are emergencies or not. Heck, we often can’t, particularly without seeing the patient first (and even then…). And frankly, that’s just not where the money is. Policies that attempt to identify which patients didn’t need to be in the ER for “non-emergency visits” punish patients who don’t have other options, can’t tell what is or is not an emergency, and punishes ERs for treating them.

Paul DeKoning, MD, MS

A ridiculous concept in my mind. It’s really quite easy to say a patient’s chest pain wasn’t cardiac or an emergency after they’ve had their workup and we’ve excluded life-threatening etiologies. That’s actually what we are trained to do. It’s my job and it’s yours. Let Emergency Physicians make that call. Not insurers.

William Sullivan, DO, JD

We’re missing the point in the article. The new NJ law caps reimbursement for emergency department care provided to Medicaid patients when that care is deemed “non-emergent.” The law doesn’t say that patients need to diagnose their own emergencies, but rather that if a patient is treated in the emergency department for a non-emergent condition (which the law will define), then hospitals won’t be reimbursed more than $140 for the visit. Several points in the article are pertinent. It cites studies showing that Medicaid patients utilize the emergency department twice as much as those with private insurance. Causes are reportedly lack of access to care, but also allegedly due to “convenience” and hospital encouragement of inappropriate ED use.

On one hand, I applaud the legislature for trying to come up with an idea to curb ED overuse. On the other hand, I’m betting that the unintended consequences will encourage hospitals to overtreat or overdiagnose patients in order to make them appear as if the visit was not “non-emergent.” Will be interesting to see distribution of hospital charges before and after the law takes effect.

This is an example of how non-medical types will come up with their own solutions to a health-related problem when we complain about an issue but fail to address it ourselves. When we start advancing the notion that every malady of human existence is an emergency medical condition until ruled otherwise by a trained emergency physician, we lose credibility with the public and with the legislatures that create the laws affecting our practice.

Seth Trueger, MD MPH FACEP

Bill, you name a few issues but miss a lot. There are plenty of reasons why homeless patients with mental health issues don’t show up to psychiatric visits or dialysis or “refuse” to take their medications that are linked to their mental health and poverty, and lack of social support networks. It’s easy to label someone as “kicked out of shelters for failing to follow the rules” while ignoring the realities of many shelters — bed bugs, lice, physical and sexual assault.

Just as Medicaid patients don’t come to us simply out of “convenience” — this NJ proposal capping Medicaid reimbursement punishes hospitals because they are near poor patients who don’t have other options (and often have other issues, such as homelessness and mental health issues). And, the data on Medicaid patients is not as clear as the article suggests; patients with Medicaid use the ED more than patients with private insurance (but not quite twice as much) but the same as patients with Medicare — who are generally, by definition, older and sicker.

William Sullivan, DO, JD

Seth, you’re proving my point. You give all of these additional reasons that people may not want to go to shelters, but the “realities” of shelters don’t make emergency departments de facto shelter inspectors and shouldn’t make emergency department beds a reward for those who are kicked out of shelters, which I see regularly. You say that “Medicaid patients don’t come to us simply out of ‘convenience’,” but that simply isn’t true. A quick Google search flags this post where Medicaid patients were interviewed and stated that they DO come to the ER for … convenience.

You argue that there are poor patients who are homeless, who have mental health issues and who are sicker, but you don’t address the point of the law: How can inappropriate emergency department use in these populations be decreased? Society — and apparently some legislatures — seem to think that giving such patients carte blanche isn’t appropriate.  Emergency medicine isn’t doing much about the issue aside from pointing out reasons without solutions. You want more regulations? This is how you get more regulations.

ABOUT THE AUTHORS

SENIOR EDITOR
Dr. Sullivan, an emergency physician and clinical assistant professor at two residency programs in Illinois, is EPM's resident legal expert. As an attorney specializing in healthcare issues, Dr. Sullivan represents physicians and has published many articles on legal aspects of medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians' Medical Legal Committee.

SENIOR EDITOR
A specialist in emergency medicine informatics at Mount Sinai in Manhattan, Dr. Genes is EPM's resident tech guru. He practices emergency medicine at Mount Sinai Hospital but can be found sharing his wit and wisdom all over the web.

SOCIAL MEDIA EDITOR
Dr. Trueger is an emergency physician at Northwestern University and Assistant Social Media Editor at Annals of Emergency Medicine. He tweets as @MDaware and blogs at mdaware.org

Dr. DeKoning is an assistant professor of emergency medicine and program director at Dartmouth-Hitchcock Medical Center in New Hampshire.

1 Comment

  1. John G. Boulet M.D. on

    The general public cannot be expected to know what is or is not an emergency.

    I would give every person on taxpayer-provided medical care an “allowance” to spend on emergencies — say, $250 or $500 per year. Every time the patient visits the ED, $50 is deducted. Those who do not use the allowance get money on December 1st for the preceding year. Those who do use the entire allowance — whether out of irresponsibility or ignorance, or simply because they have myriad medical problems that truly cause emergencies to occur frequently — are instructed to count their blessings — that they have ready access to great medical care.

    Those who neglect their own medical care for the sake of the money, need to be told to look into the mirror for whom to blame. Ditto for their families who might claim that “grandpa” or “grandma” had come to rely on that money every December 1st to keep from freezing to death or from starving to death. At which point the family is told that the money was not there before, and that it is the family’s responsibility to provide these things.

    Ah, but there’s that forbidden word: “responsibility”! Is it too much to ask for a little?

    In order to implement such a system, there would have to be some sort of biomarker or ID for every patient participating. Say, for example, iris scans, or facial recognition scans. A small price to pay for the “freebie” of great medical care at a moment’s notice.

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