1. Medicaid ER Budget Proviso
Scott Best RN
Clinical Nurse Advisor to PRC
Health Care Authority
June 11th 2012

2. Original budget proviso
Page - 191
Emergency Room Utilization - Effective July 1, 2011, the Medical Assistance Program will pay for no more than three emergency room visits for non-emergent conditions per enrollee per year. Hospitals may directly bill enrollees for the fourth and subsequent visits for non-emergent conditions and are encouraged to work with enrollees and primary care providers to avoid earlier such visits. (General Fund-State, Hospital Safety Net Assessment Account-State, General Fund-Federal)
Aimed at ED Superusers who are abusing Emergency Departments and Medicaid. Struck down by judge. Arbitrary and capricious.

3. Previous proviso
- Page 84
The department shall collaborate closely with the Washington state hospital and medical associations in identification of the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered.
All ED visits for low acuity reasons would be denied because of wrong place of service. No need to change any rules this is allowed under normal operation of a Medicaid program. Just like we would not cover brain surgery in the dentist office. Initially set to be instituted on April 1st 2012.

4. Current budget proviso
- Page 107
In order to achieve the twelve percent reduction in emergency room expenditures in the fiscal year 2013 appropriations provided in this section, the authority, in consultation with the Washington state hospital association, the Washington state medical association, and the Washington chapter of the American college of emergency physicians shall designate best practices and performance measures to reduce medically unnecessary emergency room visits of medicaid clients.
The Washington state hospital association, the Washington state medical association, and the Washington chapter of the American college of emergency physicians will work with the authority to promote these best practices.
The best practices and performance measures shall consist of the following items: (a) Adoption of a system to exchange patient information among emergency room departments on a regional or statewide basis; (b) Active dissemination of patient educational materials produced by the Washington state hospital association, Washington state medical association, and the Washington chapter of the American college of emergency physicians that instruct patients on appropriate facilities for nonemergent health care needs; (c) Designation of hospital personnel and emergency room physician personnel to receive and appropriately disseminate information on clients participating in the medicaid patient review and coordination program and to review monthly utilization reports on those clients provided by the authority; (d) A process to assist the authority's patient review and coordination program clients with their care plans. The process must include substantial efforts by hospitals to schedule an appointment with the client's assigned primary care provider within seventy-two hours of the client's medically unnecessary emergency room visit when appropriate under the client's care plan; (e) Implementation of narcotic guidelines that incorporate the Washington chapter of the American college of emergency physician guidelines; (f) Physician enrollment in the state's prescription monitoring program, as long as the program is funded; and (g) Designation of a hospital emergency department physician responsible for reviewing the state's medicaid utilization management feedback reports, which will include defined performance measures. The emergency department physician and hospital will have a process to take appropriate action in response to the information in the feedback reports if performance measures are not met. The authority must develop feedback reports that include timely emergency room utilization data such as visit rates, medically unnecessary visit rates (by hospital and by client), emergency department imaging utilization rates, and other measures as needed.

5. Current - continued
The authority may utilize the Robert Bree collaborative for assistance related to this best practice. The requirements for best practices for a critical access hospital should not include adoption of a system to exchange patient information if doing so would pose a financial burden, and should not include requirements related to the authority's patient review and coordination program if the volume of those patients seen at the critical access hospital are small. Hospitals participating in this Medicaid best practices program shall submit to the authority a declaration from executive level leadership indicating hospital adoption of and compliance with the best practices enumerated above. In the declaration, hospitals will affirm that they have in place written policies, procedures, or guidelines to implement these best practices and are willing to share them upon request. The declaration must also give consent for the authority to disclose feedback reports and performance measures on its web site.
 The authority shall submit a list of declaring hospitals to the relevant policy and fiscal committees of the legislature by July 15, If the authority does not receive by July 1, 2012, declarations from hospitals representing at least seventy-five percent of emergency room visits by Medicaid clients in fiscal year 2010, the authority may implement a policy of nonpayment of medically unnecessary emergency room visits, with appropriate client and clinical safeguards such as exemptions and expedited prior authorization. The authority shall by January 15, 2013, perform a preliminary fiscal analysis of trends in implementing the best practices in this subsection, focusing on outlier hospitals with high rates of unnecessary visits by Medicaid clients, high emergency room visit rates for patient review and coordination clients, low rates of completion of treatment plans for patient review and coordination clients assigned to the hospital, and high rates of prescribed long-acting opiates. In cooperation with the leadership of the hospital, medical, and emergency physician associations, additional efforts shall be focused on assisting those outlier hospitals and providers to achieve more substantial savings. The authority by January 15, 2013, will report to the legislature about whether assumed savings based on preliminary trend and forecasted data are on target and if additional best practices or other actions need to be implemented. If necessary, pursuant to RCW (1)(c), the authority may employ emergency rulemaking to achieve the reductions assumed in the appropriations under this section. Nothing in this subsection shall in any way impact the authority's ability to adopt and implement policies pertaining to the patient review and coordination program.

6. What does all this mean We have to have 12% reduction in ER Cost.
HCA in cooperation with WSHA and Washington ACEP is developing and instituting Best Practices and Attestation that are designed to decrease ED utilization.
Attestation must be signed by Hospitals Representing 75% of all emergency room visits by July 1st 2012.
HCA must report to Legislature whether savings are on target by January 15th 2013.

7. What are the Best Practices
A) ELECTRONIC HEALTH INFORMATION
Adoption of an electronic system on a regional or statewide basis to exchange patient information among emergency departments of participating hospitals.
B) PATIENT EDUCATION
Active dissemination of patient educational materials produced by the Washington State Hospital Association, Washington State Medical Association, and the Washington Chapter of the American College of Emergency Physicians which instructs patients on the appropriate settings for health care.
C) PRC CLIENT INFORMATION
Designation of hospital personnel and emergency department physician personnel to receive and appropriately disseminate information on Medicaid clients, including a list of clients enrolled in the Patient Review and Coordination (PRC) program and monthly utilization reports for those clients.
D) PRC CLIENT CARE PLANS
A process to assist Medicaid clients enrolled in the Patient Review and Coordination (PRC) program with their care plans. The process must include documented efforts to make an appointment for a PRC client to see the assigned primary care provider within a maximum of hours of the client's emergency room visit when follow-up by a primary care provider is appropriate under the client's care plan.

8. Best Practices - continued
E) NARCOTIC GUIDELINES
Implementation of narcotic guidelines that incorporate the Washington Chapter of the American College of Emergency Physician (ACEP) guidelines.
F) PRESCRIPTION MONITORING
Physician enrollment in the state's Prescription Monitoring Program. (The prescription monitoring program is an electronic online database used to collect data on patients who are prescribed controlled substances.)
G) USE OF FEEDBACK INFORMATION
Designation of a hospital emergency physician and hospital staff responsible for reviewing the state's Medicaid utilization management feedback reports and taking appropriate action in response to the information in the feedback reports.

9. Whats in the PRC Utilization Reports
This report contains all PRC clients who are restricted to your hospital or have used your hospital in the year previous to the report.
1. These reports are designed to be sent to an individual hospital listed on the second line
2. Each client is listed by name and date of birth.
3. Client utilization counts for the previous year are listed below the client name
a. ER Count Here is the number of times the client was in the hospital on the second line. If this number is zero it means this client in on your report because you are the assigned hospital.
b. Distinct ER Providers is a count of different hospital Emergency Departments the client visited in the previous year.
c. Total ER Visits is the total number of ER visits at all hospital Emergency Departments the client visited in the previous year.
4. Assigned Hosp: is the clients assigned hospital under PRC. If this is different from the individual hospital listed on number 1 above then this client was placed on this report because they have used your hospital in the last year.
5. SA Dx is the count of times the client received a Substance Abuse (SA) diagnosis from an ED in the previous year and Last: is the date of the last time they had a SA diagnosis. Note they could receive multiple SA Dx’s in one visit.
6. MH Dx is the count of times the client received a Mental Health (MH) diagnosis from an ED in the previous year and Last: is the date of the last time they had a MH diagnosis. Note they could receive multiple MH Dx’s in one visit.
7. The PRC restrictions section will show all non-hospital providers the client is assigned to in the PRC program and the date they were assigned as well as contact information. If the client comes to your ED for a lower acuity problem then you would use this to communicate with and refer the client back to their PCP. You can also contact the assigned pharmacy to see if the client has recently filled prescriptions.

10. What about the feedback reports
Still being developed (Draft)
Based On Emergency Department (ED) usage and drugs prescribed in ED
Population groups are All Medicaid, PRC and Clients with high number (Currently 5) of ED visits.
All ED Visits and ED visits with low acuity diagnoses.

11. Questions?