Alabama Medicaid targets ED overuse, but not with copays

Alabama Medicaid hasn't made any changes to its copays, which are $3 for outpatient hospital visits and exempted for emergencies, nursing home patients, pregnant women, children or patients receiving family planning services, and doesn't intend to do so, according to the state's Medicaid medical director, Robert Moon, MD.

Alabama's Medicaid program is taking steps to address ED overuse, however, by monitoring clients with a high number of ED visits, says Dr. Moon.

If a recipient has been to the ED five or more times in the past quarter, he explains, they're referred to the state public health department for care coordination. Currently, Alabama Medicaid is starting up pilot care networks in three regions with an enhanced case management component, reports Dr. Moon, and individuals overusing the ED will be prime candidates for this service.

"Our eligibility levels are so low, particularly for adults, that copays have not been our focus. Basically, you are taking money out of the hospital's pocket," says Dr. Moon. "Our focus has been care management, via the health department interventions."

Although the health department's care managers will continue to be utilized, says Dr. Moon, the networks will provide additional care management. "Part of what they are charged with is assessing high utilizers," he says. "Decreasing the number of ER visits and readmissions is going to be our major focus."

The care networks, which were approved by the Centers for Medicare & Medicaid Services in May 2011, are modeled after Community Care of North Carolina's, says Dr. Moon, and started delivering services in August 2011.

"In North Carolina, where they have similar networks that have been in existence for several years, their ER utilization has decreased," notes Dr. Moon.

Better continuity of care

Between the case managers newly hired by the networks and the health department's case managers, which have been in place for several years, says Dr. Moon, the expectation is that high ED utilizers will get much better continuity of care. The hope, he says, is that they will use their primary care physicians for needed care and avoid the emergency department for non-emergent conditions.

Of the 80,000 Medicaid clients in the three regions, two patients had been to the ED 53 times in a single year, says Dr. Moon. "Obviously, there is either an unaddressed medical problem or just a pattern of utilizing the ER for lots of things, that needs to be addressed," he says. "Even if we could get 53 visits a year down to 25, I would consider that a win."

Most Medicaid recipients are assigned a medical home and either choose a primary care physician or are assigned one, says Dr. Moon. "Access is certainly available to them. Part of it is them just learning to use it," he says. "Some of these folks might not even be aware they have a primary care physician."

Providers and the networks are being encouraged to contact patients who have never been seen at the practice, says Dr. Moon, and to contact previous patients who have been high ED utilizers to encourage more frequent office visits.

To help align incentives, a shared savings program rewards primary care doctors for appropriate ED utilization by their patients, says Dr. Moon. "We also pay them a case management fee for each member, to help reward the work done in facilitating that each patient gets the right care in the right setting," he adds.

Data such as the average number of ED visits per patient per year will be analyzed, says Dr. Moon, as well as data on outliers. While the five visits per quarter is a flag for individuals to be contacted by case managers in the public health system, the regional networks will be reaching out to anyone they think is overusing the ED, he explains.

"We hope to address the issue even more aggressively than that," says Dr. Moon. "If the networks think five times a year is too much, they're going to be targeting those patients for interventions. We want better continuity of care for patients, and you're not going to get that in the ER."

Contact Dr. Moon at (334) 242-5619 or robert.moon@medicaid.alabama.gov.