Presentation on theme: "Reducing Inappropriate Emergency Department Use in Utah Kevin McCulley Association for Utah Community Health (AUCH) Nancy Cheeney Utah DOH, Health Care."— Presentation transcript:
Reducing Inappropriate Emergency Department Use in Utah Kevin McCulley Association for Utah Community Health (AUCH) Nancy Cheeney Utah DOH, Health Care Financing Bureau of Managed Health Care
Defining Ambulatory Care Sensitive (aka Primary Care Sensitive) emergency department visits Based on a New York University algorithm that codes ED visits as: Non-emergent Emergent but primary care treatable Emergent, ED needed but preventable/avoidable Emergent, ED needed, not preventable/avoidable Other (injuries, mental health, substance abuse, etc.)
Common ACS Diagnoses Bacterial Pneumonia Congestive Heart Failure Complications of Diabetes Asthma Dehydration UTI Chronic Obstructive Pulmonary Disease Hypertension Severe ENT infections
Scope of the Problem The Utah Health Data Committee found: 4/10 ED visits were PCS from 2001-5 58% of Medicaid enrollee visits, and 51% of uninsured ED visits were PCS in 2005 The largest increase in PCS visit rates was for the uninsured, from 46% to 51% between 2001-5 The uninsured had 21,693 PCS ED visits in 2005
History In the past the Bureau of Managed Health Care has conducted two other ED “studies.” Mailed questionnaire in 1989 Face-to-face interviews in the ED in 1992 Study prompted policy changes Tiered reimbursement for use of ED Authorized Diagnoses for Emergency Department Reimbursement After hours / weekend differential Modified later … paid only if outside normal office hours and for existing patients only
Emergency Room Diversion Grant Goals Divert Medicaid recipients from seeking treatment in the ED for non-emergent conditions Educate targeted recipients on proper use of the ED through timely contacts Locate primary care providers for targeted recipients PCP and Urgent Care Additional education for providers and staff
Expected Outcomes Decrease inefficient use of health care resources Reduce non-emergent ED utilization Lower overall Medicaid expenditures Sustain intervention program through demonstrated savings
Target Population Initial phase Develop claims surveillance tool 15 – 54 year olds Weber, Davis, Salt Lake and Utah counties FFS and Select Access enrollees only Second phase Ages 15 and older as of October 2008 Statewide as of December 2008
Intervention Criteria Use the Utah Medicaid Authorized Diagnoses Look at primary diagnosis only Look at claims 2 weeks prior to surveillance date FFS and Select Access only
Changing Behavior Education Direct contact Grant program staff Phone questionnaires HPR staff LHD staff Medical community Mailed questionnaires Printed educational material Website www.health.utah.gov/safetowait
Is it Safe to Wait? Your PCP is a good choice After hours / urgent care clinic could meet the medical need Go to the nearest emergency medical facility Yes! It’s safe to wait... It really shouldn’t wait too long ………………. No, there could be death or permanent injury.………………….
Primary Care Provider Benefits Knows you and your medical history Not a “brand new sheet of paper” Will usually work you in for a same day appointment Peace of mind from knowing who to call for medical care
Urgent Care Facilities Point out the Benefits No appointments Lower co-pay than ED - $3.00 vs. $6.00 Shorter wait time to be seen
Sources Utah Department of Health, Utah Health Data Committee; “Challenges in Utah’s Health Care”; June 2007. Janida Grima; Health Care and GIS Class Final Project; May 2008. Association for Utah Community Health; “The Impact of Medical Homes and Access to Primary Health Care on Health Care Costs”; June 2008.