Florida Emergency Department Collaborative June 8, 2011

1. Florida Emergency Department CollaborativeJune 8, 2011 Presented by: Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical Officer Margaret deHesse, RN, BSN, Executive Director State and Corporate Services

2. Overview • Goal of the Emergency Department (ED) Collaborative • Objectives of the ED Collaborative • Characteristics of ED populations • National and Florida ED utilization • ED utilization analysis – HMO/PSN • Key drivers of inappropriate ED use • Conclusions • Timeline

3. Goal of the ED Collaborative • Reduce unnecessary ED utilization among Florida Medicaid managed care recipients through a collaborative effort • Effectiveness of current Florida-specific ED strategies • Challenges in managing consumer and provider behaviors resulting in inappropriate ED utilization • Need to address ED utilization at a systems level

4. Goal of the ED Collaborative • Direct managed care consumers to seek care in the most appropriate setting and to reduce ED use in non-emergent situations • Leadership required to direct the effort • Identify the priorities • Identify the stakeholders • Identify possible solutions/strategies

5. Characteristics of ED Populations • National Hospital Ambulatory Medical Care Study – 2006 Emergency Department Summary, DHHS, CDC, August 2008. • Medicaid consumers visit the ER more frequently than individuals with any other source of payment • Infants under twelve months had the highest utilization • Persons aged 75 and older were the second highest followed by persons living in nursing homes and homeless persons • Black persons visited the ERs approximately twice as often as white persons, regardless of age

6. National ED Utilization • Florida’s overall ED utilization rates have been consistently comparable to national averages.

7. Classification of ED Visits • NYU Algorithm: • Developed with advice of panel of ED and Primary Care Physicians (PCPs) after examination of nearly 6,000 full ED records by panel • Grouped ED visits into categories: • Non-emergent • Emergent Primary Care Treatable • Emergent Preventable/Avoidable • Emergent Not Preventable/Avoidable

8. Classification of ED Visits NYU ED Classification Algorithm:

9. Florida Medicaid ED Utilization Rates - Methods and Findings • Participating plans included Reform HMOs and PSNs in Broward, Baker, Clay, Duval, and Nassau counties • State fiscal year (SFY) 2010 Claims Data was employed in all ED analyses • Applied NYU algorithm to SFY 2010 ED Visits • ED utilization analysis includes results reported by: • Product type by Adult and Child • Top 10 Diagnoses by Adult and Child • Gender • Age

10. Non-Emergent/PCP Treatable/Preventable ED Visits Demographics

11. HMO/PSN ED Visits - Adult Reform HMOs Reform PSNs 43% (10,902) Emergent Not Preventable/ Avoidable ED Visits • 57% (13,949) • Non-Emergent ED Visits • Primary Care Treatable • Preventable/Avoidable 43% (10,588) Emergent Not Preventable/ Avoidable ED Visits • 57% (14,502) • Non-Emergent ED Visits • Primary Care Treatable • Preventable/Avoidable

12. HMO/PSN ED Visits - Child Reform HMOs Reform PSNs 44% (18,629) Emergent Not Preventable/ Avoidable ED Visits • 56% (25,528) • Non-Emergent ED Visits • Primary Care Treatable • Preventable/Avoidable 44% (19,740) Emergent Not Preventable/ Avoidable ED Visits • 56% (23,993) • Non-Emergent ED Visits • Primary Care Treatable • Preventable/Avoidable

13. Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Adult Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non-emergent/PCP treatable/preventable.

14. Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Child Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non-emergent/PCP treatable/preventable.

15. Summary of Findings • When evaluating product type (i.e., HMO vs. PSN), there is little to no variation in the percentage of non-emergent, PCP treatable, and preventable/avoidable ED visits for both the adult and child populations • In comparing the top ten diagnoses of non-emergent, PCP treatable, and preventable/avoidable ED visits between the adult and child populations three common diagnosis were identified: • Upper respiratory infections • Abdominal pain • Skin and subcutaneous tissue infections

16. Key Drivers of Inappropriate ED Use • Consumers • Inadequate logistical access to primary care services • Lack of knowledge about when to use primary care, urgent care, and emergency care • Lack of alternatives to the ER for after-hours health care • Lack of convenient or “open” appointments • Lack of access for specialty and behavioral health services • Lack of disincentive for use of the ER for non-emergency conditions

17. Key Drivers of Inappropriate ED Use • Primary Care Providers (PCPs) • Lack of alternative methods to address and treat emergency call needs • Lack of member/PCP relationship (educational opp.) • Lack or absence of a provider phone message • Lack of incentives for providers to provide after hours care

18. Key Drivers of Inappropriate ED Use • Managed Care Plans • Lack of a consistent approach regarding when to use primary care, urgent care, and emergency care • Lack of timely communication between the ED and managed care plans • Lack of member education on ED use • Lack of timely information about members accessing care in the ED

19. Key Drivers of Inappropriate ED Use • Emergency Department • Hospitals treat consumers who present, citing the federal Emergency Medical Treatment and Active Labor Act (EMTALA) - 1986 • Consumers can receive health care regardless of resources or time of day • Lack of incentives for hospitals to reduce ED utilization • Lack of communication with managed care plans and providers

20. Conclusions • Geographic factors, chronic health conditions, and primary care access are all predictors of ED utilization patterns for Medicaid recipients • Potentially successful strategies include increased access to primary care and managed care interventions • Reducing avoidable emergency care will require greater coordination among EDs, Health Plans, PCPs, and consumers • There is no “gold standard” regarding initiatives to reduce avoidable visits to the ED

21. Timeline

22. Florida Emergency Department Collaborative Questions