Program for uninsured cuts ED visits, admissions

Health system creates HMO-like system

Faced with a growing uninsured population, The MetroHealth System in Cleveland created an HMO-like system in 2010 to provide care for uninsured patients and embedded case managers in the health system's 11 clinics to ensure that uninsured patients get the care they need to avoid emergency department visits and hospitalization.

The case managers embedded in the clinics are hospital employees and work only with uninsured patients. "We pay the case managers' salaries. We can't afford not to because we're going to be providing care for uninsured patients with no reimbursement. By ensuring that they receive better health care, we are helping them stay healthy and avoid emergency department visits and hospitalization," says Alice Stollenwerk Petrulis, MD, medical director for care management at the 500-bed MetroHealth Medical Center, a safety net public hospital.

The program has saved the hospital about $18 per member per month for uninsured patients who are in the HMO and reduced utilization by ensuring that patients are treated at the appropriate level of care.

"We know that most of our admissions come from the emergency department. If patients wait until they are very sick to go to the emergency department, they're likely to be admitted. If we help them keep their chronic conditions under control, we can keep them healthy and they'll stay out of the emergency department and the hospital," she says.

Uninsured patients are categorized into five different plans with varying co-pays, depending on their income levels. For instance, patients who are extremely needy, such as the homeless, are in Plan 0. Those whose income is 400% of the federal poverty level are in Plan 400. The patients pay nominal co-pays for office visits and receive a deep discount on surgical procedures. The HMO is open only to Cuyahoga County residents.

The patients in the MetroHealth HMO are assigned to a primary care provider and cannot see a specialist unless their primary care physician refers them. "We require prior authorization similar to commercial payers," Petrulis says. When patients need procedures such as surgery, MRIs, and PET scans, a prior authorization nurse reviews the patients' medical records using Milliman guidelines for medical necessity and contacts Petrulis if they cannot approve the request. Petrulis reviews the case using clinical judgment and to determine whether to approve or deny a request.

When uninsured patients go to the emergency department, the financial department staff get the process of signing them up for the HMO started. Patients cannot have a clinic appointment unless they have insurance or have been rated under the program. When uninsured patients who are not a part of the program try to make a clinic visit, they are advised to sign up for the HMO.

Providers in the health system's satellite clinics refer uninsured patients who have chronic conditions or multiple medical problems to the hospital's case managers embedded in the clinic. The case managers educate the patients on their conditions and treatment plan, help them with applications for medication discount programs, make sure they have follow-up care, and remind them of clinic appointments.

When patients in the program are discharged from the hospital, the case managers make sure they have a follow-up appointment and call them to remind them.