Hospital Emergency Department Use and Its Impact on the State Medicaid Budget

1. Hospital Emergency Department Use and Its Impact on the State Medicaid Budget Program Review and Investigations Committee

2. PRI Committee • Oversight committee of Connecticut General Assembly • Uniquely bi-partisan - 6 Democrats, 6 Republicans, and equal members from Senate and House • 2 co-chairs – one from each party and chamber – rotates every 2 years • Staff of non-partisan analysts • This study topic chosen by committee after discussions with leaders of Appropriations and Human Services

3. Study Focus • Examine use of Emergency Departments (EDs) by Medicaid Clients: • Utilization and costs of ED care for Medicaid clients and impact on Medicaid budget • Frequent use of ED by Medicaid clients and strategies to prevent or divert clients • Access to health care for HUSKY clients compared to individuals with other types of insurance

4. Study Challenges • Complex system with many entities involved • Several initiatives to better coordinate health care – all at different stages of planning or implementation • Availability of Medicaid data were limited since ED data not routinely run by DSS

5. Study Methods • Interviews with state agencies, ASOs, other interested parties • Visits to several hospital EDs and discussions with ED physicians • Analysis of Medicaid client claim data provided by CHN • FQHC visits and interviews • Surveys of hospital EDs and FQHCs • MAPOC website materials • Review of literature

6. Study Milestones in Brief • Committee approved Scope of Study -- June 2013 • Staff presented initial information and findings to committee in September 2013 • Committee held an informational public hearing in September • Meeting to discuss Findings and Recommendations January 31, 2014 – approved report - Findings and Recommendations • Raised a bill RB 5378 – held 2 community public hearing on bill • Incorporated many changes and approved yesterday

7. Presentation Areas • Overview of ED Utilization in Connecticut • Medicaid Utilization and Costs • Access to Care for Medicaid Clients • Intensive Case Management • Controlled prescription drugs and ED visits

8. Federal Emergency Medical Treatment & Labor Act (EMTALA) • Signed into law in 1986 • Ensures public access to emergency services regardless of ability to pay • Three basic obligations under EMTALA • Any individual who comes and requests examination or treatment of a medical condition must receive a medical screening examination by a qualified medical provider to determine whether an emergency medical condition exists. • If an emergency medical condition exists, treatment must be provided until it is resolved or stabilized. If the hospital does not have the capability to stabilize the emergency medical condition, an "appropriate" transfer to another hospital must be done in accordance with the EMTALA provisions. • Hospitals with specialized capabilities must accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.

10. Source: Department of Public Health (DPH) Office of Health Care Access (OHCA)

11. Most people visiting an ED are treated and discharged – about 85 percent of all visits For all ED visits, about 15 percent of individuals were admitted to inpatient Only about 7 percent of ED visits by Medicaid clients resulted in an inpatient admission Source: DPH Office of Health Care Access

13. Medicaid clients had the greatest percentage of ED visits (36%) but only represent 16.5% of Connecticut’s population ED Visits by people with commercial insurance accounted for about 31% of total visits even though they represent about 52 percent of Connecticut’s population Source: DPH, OHCA

16. 267,700 Medicaid clients visited an ED • There were 605,506 visits by these clients • Medicaid reimbursements was slightly more than $229 million • Average cost per ED visit - $350 • Average cost per ED patient - $791 ED Cost/Use by Medicaid Recipients (No Inpatient Admission): CY 12

17. Finding • ED visits by Medicaid clients are not a major cost driver of the overall Medicaid budget • Higher rates of ED utilization by Medicaid clients compared to the rest of the population suggest better access to community health care could improve health outcomes

18. Recommendation (#1) • The Department of Social Services should: • develop brochures about alternatives available to the emergency department if a client does not need immediate attention. • The brochures should be made available to clients at federally qualified health centers and primary care offices with high Medicaid patient caseloads.

21. Reasons for Frequent Use of ED • Acute medical conditions • Chronic medical conditions • Need access to specialists • Behavioral health • mental health • alcohol • drug-seeking behavior

22. ED usage patterns show about 52% of the 267,700 Medicaid clients who had an ED visit in CY 12, visited only once About 8% of the 605,506 ED visits in CY 12 had a primary diagnosis of behavioral health, including 2% as alcohol-related There is no commonly accepted definition of a frequent ED user, but 4,671 clients had 10 or more visits to an ED in CY 12

23. Source: DSS

24. Recommendation (#2) • The Department of Social Services should report annual ED use by Medicaid clients including: • a breakout of the number of unduplicated clients visiting an emergency department • clients with 10 or more annual visits to any ED • The department should use this information to monitor contractor performance, particularly with linking frequent users of emergency departments to primary care providers following an ED visit. • The report should be provided to the Council on Medical Assistance Oversight

25. Presentation Areas • Overview of ED Utilization in Connecticut • Medicaid Utilization and Costs • Access to Care for Medicaid Clients • Intensive Case Management • Behavioral Health, Substance Abuse and ED visits

26. Medicaid Access • Most other states cover Medicaid population through managed care organizational model • Capitated rate from state to MCO to cover members • MCO takes financial risk • Connecticut used MCO model for HUSKY A and B until 2012 • Abandoned the model because of legal issues and questions about rates and adequate coverage • HUSKY C and SAGA clients had always been Fee-for-Service • Now all populations are covered under an Administrative Services Organization model (hybrid) • State assumes financial risk – Medicaid ASOs to assist with aspects of care

27. Roles and Responsibilities: • Member and provider services • Referral assistance and appointment scheduling • Provider recruitment • Health education • Utilization management • Case management including intensive case management • Quality management • Health data analytics and reporting • Not responsible to pay claims Source: DSS Presentation to Appropriations Subcommittee, February, 2012 Administrative Services Organization

28. Alternatives to Hospital ED • Medicaid population biggest user by payer source • Hospital Emergency Department use by people with private insurance has dropped For privately insured clients: • co-pays for ED use – avg. about $75 up to $150 • Many urgent care centers, located in suburbs, with low co-pays ($20 -$30) • Minute clinics • Promotion of preventive and primary care through lower insurance premiums, etc.

29. Alternatives To Hospital ED: Medicaid • Many of the options are not available or not easily implemented with Medicaid • Co-pays authorized in 2013 session – not implemented yet • National studies indicate co-pays not effective tool • Clients need assurances that other alternatives exist • Better education of clients about alternatives and benefits of using them vs. ED

30. Alternatives to ED • Ample supply of primary care providers • CT ranks high in supply of physicians and other primary care for overall population • But access for Medicaid clients not the same • Rates have historically been much lower • Access to primary care will be important as Medicaid expands under the ACA

31. Medicaid: Measuring Access • Administrative Services Organizations measure access • Measured by Geo Access shows very high percentage of Medicaid clients have access • Limitations • Does not measure providers not accepting new Medicaid clients • Length of time for an appointment • Access to urgent care

32. Medicaid: Measuring Access • Another measure that ASOs use is mystery shopper survey • Would reveal those issues about appointment time, etc. • Required by contract to produce this annually – not been done in a while • Will become even more important when providers are paid enhancements to manage and coordinate care Recommendation # 3 DSS require ASOs to annually conduct mystery shopper survey and report results as required

33. Medicaid Access • Network of primary care providers enrolled in Medicaid has increased • Physicians from 1,362 to 2,441 • Physician assistants and APRNs – from 260 to 777 • Much of expansion result of rate increases under ACA • Primary care Medicaid services reimbursed at Medicare rates • Some rates almost doubled -- $67 to $123 • Fully federal reimbursement for 2 years

34. Medicaid Access: Attribution • Another ASO responsibility is to “attribute” or link patients to a primary care provider • Clients can choose or ASO “attributes” based on claims data • Overall rate of about 64 percent • Approximately 80 percent of children have been linked to a primary care provider, but only about 50 percent of adults • Even lower for attribution to patient-centered medical homes

35. Medicaid Attribution • Low attribution rate indicates people are not getting primary care • ASOs need to take a more assertive approach Recommendations # 4 and # 5 • At earliest stages -- when a client enrolls in Medicaid -- ASO should contact about primary care providers in area • Promote advantages of being in a Patient-Centered Medical Home • Work with client to make appointment • Primary care provider and contact information on enrollee’s Medicaid card

36. Medicaid Access: Continuous Eligibility • Another deterrent to accepting a Medicaid client is uncertainty of eligibility • Important to achieve predictability and stability in Medicaid eligibility as expansion occurs • To help with access and continuity of care • National studies show average per member monthly costs are less longer a person is covered • Limit provider risk in getting reimbursed

37. Medicaid Access: Continuous Eligibility • Federal Medicaid agency suggests a number of strategies to help states with Medicaid expansion • Continuous eligibility is one CMS-suggested strategy • CT had continuous eligibility for children until 2003 • Connecticut could resume for children unilaterally • Need to seek an amendment to waiver for adults Recommendation # 6 Legislature adopt 12-month continuous eligibility for children and DSS seek a approval from CMS for continuous eligibility for adults

38. Medicaid: Access to Specialists • Cited as persistent problem in Medicaid • Low reimbursement rates – less than 80% of Medicare rates • Specialist rates not subject to boost under ACA • Primary care providers and FQHCs spend many hours trying to get specialist appointments – often have very long waits • Need to develop other strategies to improve access

39. Medicaid: Access to Specialists • Many other states are authorizing some Medicaid services be provided by • telemedicine or telehealth • rather than face-to-face • CMS allows for Medicaid reimbursement • One of the FQHCs has developed an initiative with specialists at UCHC for telehealth • These efforts would increase access to specialists

40. Medicaid: Access to Specialists • DSS statutorily authorized to develop a demonstration project with a FQHC to develop telemedicine initiative • DSS not done that yet – analyzing with UCHC –results in March Recommendation # 7 Require DSS to engage in a demonstration project using telemedicine or telehealth and report on results and possible expansion tohuman services and appropriations committees

41. Medicaid: Overall • CHNCT reported mostly positive overall outcomes for all Medicaid clients with ASO model: • Inpatient admissions declined by 3.2% • Inpatient days decreased by 8.1% • Average inpatient stay ↓ from 5.4 days to 5.1 days • Cost of inpatient stay ↓ from $7,545 to $7,345 • ED visits declined 3.2% but costs increased 8.5%

42. Medicaid: Intensive Case Management • Another responsibility of various ASOs • Which ASO and type of case management depends on Medicaid population and services needed • Examined the ICM services by CHNCT, ValueOptions, Advanced Behavioral Health, and one by Middlesex Hospital

43. Medicaid Intensive Case Management • CHNCT conducts ICM primarily for chronic medical conditions • Higher priority of clients with inpatient admissions • Clients are not required to participate • CHNCTengages about 40 percent of members identified • Outcomes 6 months pre and 6 months post ICM 1/1/12 and 10/1/12 • 43% decrease in inpatient admissions • 6% reduction in ED visits

44. Medicaid: Intensive Case Management • ValueOptions – Primarily behavioral health ASO • Coordinates with CHNCT for those clients with dual diagnosis • In 2011 PA report on ED use by 41,049 adult clients with BH showed; • 12% had readmits to ED within 7 days • 28% had readmits to Ed within 30 days • almost38% showed no indication of follow-up outpatient after ED

45. Medicaid: Intensive Case Management • Provider Analysis report on ED use has not been produced since 2011 so unknown whether there has been improvement in this area • This report is one that is contractually required Recommendation # 8 Require DSS to better monitor the ASOs’ reporting requirements to ensure the agency is getting all contractually obligated reports, including the Provider Analysis report on ED use

46. Medicaid: Intensive Case Management • Report includes description of several intensive case management programs, including outcomes (pages 40 - 47) • Intensive case management services of the two major ASO have been Medicaid reimbursable but not those of ABH Recommendation # 9 DMHAS work with DSS and OPM to ensure that all expenditures for all eligible intensive case management services are submitted for Medicaid reimbursement

47. Intensive Case Management • ABH-reported outcomes for 2-year period: • 57% reduction in inpatient episodes • 46% reduction in costs • 18 percent decrease in ED visits • 21% cost savings • Middlesex Hospital Community Care Team Model • 59% reduction in inpatient admissions • 51% fewer ED visits • $9,329 decrease in per client hospital costs (65%↓)

48. Medicaid: Intensive Case Management • Factors associated with more positive outcomes of the various ICM programs, especially with frequent ED users: • More face-to-face contact with clients • ED knowledge and awareness of the program • ED involvement in selection of clients for ICM • ED involvement in development of care plans • ongoing (not episodic) ICM monitoring of client’s progress • frequent meetings of community providers involved in care • persistence in engaging clients and in managing care and needs

49. Medicaid: Intensive Case Management • These are factors associated with the Middlesex Hospital Community Care Team model, which showed favorable results, and should be replicated to improve outcomes, especially with frequent users of the ED Recommendation # 10 DSS and DMHAS should contractually require ICM teams to identify hospitals for CCT program based on frequent ED use and work with hospital EDs to identify clients who would benefit from CCT approach Co-locate at least one ICM staff at hospital EDs that participate at hours when ED use is highest

50. Medicaid: Intensive Case Management • Recommendation # 11 Requires these ICM staff to: • work with participating ED doctors to develop a care plan for clients who participate • have knowledge of area community services and providers • serve as liaisons between hospital ED staff and providers • meet with providers weekly to monitor progress