Limiting ER ‘over-users’ an attempt at cost control

Trouble comes knocking at Dr. Anne Zink’s emergency room door at the Mat-Su Regional Hospital near Palmer.

The patient is a middle-aged housewife, upper middle class, educated, addicted and shopping for painkillers. Zink doesn’t know that.

This is a problem.

Alaska has a state prescription drug database, but it takes time to log in and use. Zink doesn’t have time. Things move too fast in emergency rooms.

“I need this information now, in real-time. Without it, I’m practicing blind,” she said.

What Zink wouldn’t know is that the patient has been to an emergency room 34 times in the last 12 months.

There are a lot of reasons why people go to hospital emergency rooms. An accident with life-threatening injury is one; a mental health issue and no access to behavioral health help is another. Inability to pay — hospital ERs have to take all comers — is one more.

Sometimes people are just lonely and confused. Some come to Mat-Su’s ER more than 50 times in a year.  One patient with complex social and medical needs showed up 166 times last year, Zink said.

Unfortunately, shopping for painkillers and narcotics is another reason people come to ERs. This is an epidemic in Alaska and across the nation, and it is an urgent problem.

There’s some good news coming, however. Zink and other emergency room physicians in Alaska hospitals will soon be able to get real-time electronic medical information on ER walk-ins through a new project being done jointly by the state hospital association, the Alaska chapter of the American College of Emergency Physicians. (Zink is chapter president) and the state Department of Health and Social Services.

The project was authorized in Senate Bill 74, a wide-ranging health care reform bill passed by the Legislature this spring, and it will do more than help spot ER “super-users,” said Becky Hultberg, president of the Alaska State Hospital and Nursing Home Association, or ASHNA.

Hospitals will help people find more appropriate care for non-urgent needs than going to an ER, and even making appointments for patients with primary care physicians and behavioral health providers.

SB 74 requires this to be done within 96 hours of an emergency room visit.

Also, hospitals and the state health and social service department will develop uniform statewide guidelines for the prescribing of narcotics in emergency rooms. Surprisingly, this doesn’t exist now as a statewide guideline. 

The joint project is modeling on a series of highly successful emergency room best practices worked out between the state of Washington and hospitals there.

Overuse of emergency rooms had become a huge problem particularly among Medicaid patients, and in an attempt to control costs the state put a hard limit on hospital ER reimbursements for Medicaid patients.

This put hospitals in a bind because under federal law no patient can be turned away at an emergency room, Medicaid or otherwise.

“It became a kind of unfunded mandate,” which was very costly, not just for hospitals but for the entire health care system when Medicaid and Medicare pay, Zink said.

The best practices are aimed at spotting ER super-users and steering them to alternative, often better, primary or behavioral care. They were proposed by Washington hospitals and accepted by the state after a court battle over the state decision to cut off Medicaid payments.

The first-year savings target of $30 million was exceeded — it was actually $33.6 million, Zink said. Other results included an overall 9.9 percent decline in ER visits, a 10.7 percent decline in “super-users” (those defined as visiting emergency rooms 5 or more times in a year), and a 14.2 percent decline in low-urgency ER visits, she said.

These are people with colds and similar ailments who are steered to local primary care providers.

The cost-savings potential for educating patients and implementing coordinated care is huge and will include better health outcomes, Zink. The electronic information link between hospital ERs is a first step because people sometimes “shop,” going from hospital to hospital.

“Frankly, we’re siloed (cut off). It’s like there’s no highway between Palmer and Anchorage,” in providing access to patient information between hospitals, she said.

The project goes beyond prescription drugs too because it will show if a patient already has worked out a health care plan with another hospital.

Frequency of radiology and CT scans will also show up on a real-time as part of a one-page health summary. An ER physician might order a CT scan not knowing the patient has already had two or three scans at other hospitals. Too many of these create health problems.

“There are 26 institutions doing coordinated care planning between the Mat-Su and Anchorage and not having these in an accessible database leads to a lot of uncoordinated care, duplication and waste,” Zink said.

The current state database covers only prescription drugs and has had intermittent funding from the Legislature, where there have been concerns over privacy. It takes two or three minutes to log into the system Zink said.

With more than 80 people a day coming through Mat-Su’s ER, and 30,000 last year, taking two to three minutes per log-in for patients needing a prescription drug can easily translate to two to three hours a day being consumed. Changing this will result in better care at lower cost.

“An opportunity to do that doesn’t come along very often,” Zink said.

SB 74 was passed by the Legislature April 17 and is awaiting Gov. Bill Walker’s signature, but the hospitals and emergency room physicians aren’t waiting. The first planning meeting to implement the project has been held, and Hultberg thinks parts of it can be up and running in 2016 and the rest in 2017.

Hospitals will wind up funding parts of the project themselves but there may have to be funds raised for the information technology parts, she said.


05/18/2016 - 4:03pm