A patient walks into an emergency room as a blank slate to doctors, who must quickly gauge the likelihood of an acute problem. Were a doctor to know that the patient suffers from chronic headaches, that a recent CT scan didn’t reveal any problems, and that just a week earlier a doctor at a different ER told the patent to follow-up with a specific primary care physician, the slate wouldn’t be quite so blank. “All of a sudden, it changes the whole nature of the conversation with the patient,” says Dan Lessler, the chief medical officer for Washington state’s Medicaid program.
Getting doctors in Washington just that type of information is the backbone of an effort to divert patients from trips to ERs for non-urgent problems. Starting in the summer of 2012, Washington ERs began tracking patients in a mandatory, statewide database. Data (PDF) released last week show that the approach appears to be working.
ER visits by Medicaid patients fell by 10 percent in the program’s first year, and the rate of ER visits that resulted in non-acute diagnosis decreased more than 14 percent. Overall, the state says its Medicaid ER costs fell $33.7 million in the 2013 fiscal year. Because other changes to ERs were made at the time, the state says it can’t definitively attribute all the savings to this effort.
“If a patient was seen three days ago at Harbor View Medical Center and walked into Valley Medical Center 25 miles south, the treating physician might know they were seen there and might have some info about what went up,” says Lessler. “Up until that point, you never had that information.”
Some providers or hospital systems had similar networks in the past, but “a lot of systems, they don’t want to play well with their competitors,” says Nathan Schlicher, an ER doctor who serves on the board of the Washington State Medical Association. He says it took “a shared crisis” to get everyone on board—and by “crisis” he means the state’s previous efforts to trim costs as Medicaid rolls expanded during the economic downturn.
At first, Washington said it wouldn’t reimburse hospitals for more than three non-emergency ER visits per Medicaid patient a year. When doctors sued, saying the policy would make it hard to serve patients, a state court ruled in their favor. The state revised its plans and said it wouldn’t reimburse the hospitals for about 500 diagnosis codes it deemed unworthy of treatment in an ER. That provoked further outcry from doctors and hospitals, and an editorial in the New England Journal of Medicine called the approach “arguably harsher” than capping visits.
A state legislator, Representative Eileen Cody, urged detente instead of more legal fighting. After she got everyone to agree to compromise, the state, hospitals, and physicians quickly developed and adopted what they refer to as the “Seven Best Practices” (their capitalization, not mine). The idea was that if doctors in the ER had more information about patients and could pass their findings to future clinicians, patients could get help though outpatient—and cheaper—care.
The state required hospitals to adopt a new database, Emergency Department Information Exchange. As soon as patients register at an ER, their names are sent to the database; within minutes, it responds with a list of, and details about, any recent ER visits. “By the time they get your vital signs, we’ve already got a fax back,” says Schlicher.
When an ER discharges a patient, the database helps the hospitals continue to track the care. One hospital dispatches paramedics to check on high-risk patients within two days of their visit. Others hire care coordinators to follow up and make sure patients were able to get appointments with a family doctor or specialist.
“It also created a whole new set of data so hospitals and communities could look at what patients are coming back to our emergency rooms,” says Carol Wagner, senior vice president for patient safety at the Washington State Hospital Association. She said four hospitals in a rural region realized that their ERs were seeing patients who needed help with pain, so several hospitals banded together to set up the region’s first pain management clinic.
With the system up and running, Washington is looking to expand its use and capabilities. The data collected has already helped reduce prescription of narcotics for Medicaid in ERs by 24 percent in the first year; in the future the database will automatically look up a patient in a separate state repository of drug prescriptions. And the state has already signed up 424 primary care physicians to provide them automatic notifications every time one of their patients goes to the ER. Washington hopes to sign up more family doctors, as well as community and mental health clinics.
Other states are taking note. Oregon is setting up a similar program, and doctors involved in Washington’s efforts said the have answered queries from colleagues in California, Ohio, New York, Texas, and Florida. As the Affordable Care Act expands Medicaid to a greater number of patients, the need for states to keep ER costs in check will become pressing. Washington is showing how far a little data can go.
