North Carolina targets high utilization of ERs

Washington Medicaid's plan to limit non-urgent ER visits to three a year is being watched "with great interest," says Randall Best, MD, JD, chief medical officer for North Carolina's Division of Medical Assistance. "It's a hot topic in pretty much all the states right now."

According to Dr. Best, efforts to limit ER utilization in Medicaid are nothing new, but have been brought to the forefront this year due to budget shortfalls. "This is a tough budget year, so everybody is saying if people weren't going to the ER, everything would be fine," he says. "That is probably a bit of a simplification."

Individuals who get routine medical care at the ER differ from those who go to primary care physicians, explains Dr. Best, because they often present with a combination of chronic pain syndromes, substance abuse and behavioral health issues. "All of these conditions are difficult to manage," he says. "Their diagnoses often look simple, but what they present with is quite a bit different."

A patient's ear infection diagnosis doesn't tell you that he or she also has serious mental illness, notes Dr. Best, and while a sore throat diagnosis may seem non-urgent, there are rare times when it can signal a potentially fatal condition. "That is the problem with the claims data approach," he says.

While Medicaid programs are not required to provide unlimited services of any type, and all would like to reduce non-urgent ER visits, the problem is that the diagnosis is made retrospectively, says Dr. Best. "My background is in emergency medicine, so I probably look at a this a little differently than most Medicaid directors," he adds.

The Emergency Medical Treatment and Labor Act is based on whether a "prudent layperson" believes he or she may have a life-threatening emergency, adds Dr. Best, and severe pain may meet this criteria. "To me, to not reimburse the providers isn't really utilization management. It's more financial management," he says.

Targeting frequent flyer

Like Washington state's Medicaid program, North Carolina has made changes to reduce non-urgent ER utilization, but has taken a different approach, says Dr. Best. "We have not gone down the road of trying to reimburse for just a certain number of ER visits," he says. "We are trying to figure out what the root cause is for the visit."

Instead of casting a wider net to include individuals who go to the ER six or seven times a year, says Dr. Best, the focus is on a much smaller group with far higher utilization. "We are focusing on patients with massive numbers of visits. We had one patient who had 203 visits in a calendar year," he says. "I think that everyone would agree that is less than optimal care."

To get the care of this group managed more appropriately, the Medicaid program will work with its managed care partners, Community Care of North Carolina (CCNC), which three-quarters of Medicaid clients are enrolled in, says Dr. Best.

Each of CCNC's 14 primary care networks will work with individual Medicaid clients to see if they need referrals for behavioral health or chronic pain, and also to determine why they use the ER so much, says Dr. Best.

"It is a very case-by-case, labor-intensive process," he says. "If somebody is going to the ER six times a year, trying to get them down to four times isn't that easy. If somebody goes 100 times, getting them down to 75 is a lot more doable."

Reaching out to patients

Recently, North Carolina Medicaid looked at all patients with more than ten CT scans done at ERs in a single year, unrelated to trauma or malignancies, as a patient safety initiative. "A group of three of us called each patient. We didn't say, 'You need to quit going to the ER because this is costing a lot of money.' We told them there is a risk of cancer over time because of ionizing radiation," says Dr. Best.

Patients were instructed to report their previous procedures to their physicians, he adds, and were given referrals to care managers. "We have to walk a fine line. We don't want patients refusing necessary tests because of the fear of radiation," Dr. Best explains. "But patients with chronic pain complaints probably don't need as many CT scans as they're getting."

The same approach may be taken with the Medicaid program's most frequent ER utilizers, says Dr. Best, with care managers calling to inform them that obtaining routine care in the ER isn't the best way to get care, and to ask them why they use the ER so often.

A patient may go to the ER even though no emergency exists because he or she can't get in to see a primary care physician, has a mental illness that isn't being addressed, or to obtain pain medications he or she is addicted to, says Dr. Best. "Every patient is different. There is not really one easy answer to that," he says.

While private payers can discourage ER use with high copays, this is not the case for Medicaid programs, adds Dr. Best. "If Blue Cross feels like people are using ERs too much, it's very easy for them to put in a $250 copay to change that behavior," he says. "But with Medicaid, any sizable copay will probably not looked at with favor by [the Centers for Medicare & Medicaid Services]."

Even if a small copay such as $3 was added, Dr. Best says that many Medicaid patients wouldn't pay it, resulting in decreased reimbursement to providers.

"There are a lot of unintended consequences with copays," he adds, noting that North Carolina Medicaid has a copay for office visits but not ER visits. "So that's a perverse disincentive to see the physician, which is something we will look at. Maybe we don't need a copay in the outpatient setting, either."

Contact Dr. Best at (919) 855-4263 or