Washington State 7 Best PracticesDr. Stephen H. Anderson, MD, FACEP

The State Budget

2Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

Problem StatementWashington State elected not to

cover more than three visits off of

a list of over 700+ conditions

including chest pain, shortness of

breath, abdominal pain, and so

much more

3

Rationale #1

• Emergency departments

are filled with “non-

emergent visits” that

would be better treated

in their PCP office.

• What Percentage?

4

8%

Rationale #2

• Emergency Department

costs are exorbitant and

burden the healthcare

system.

• What Percentage of all

healthcare dollars are spent

in the ED?

5

2%

Rationale #3

• “Emergency Physicians and hospitals have been abusing their privilege for years billing the state for non-emergent care.”– Jeff Thompson, CMO of

Medicaid, Seattle Times, 2/2012

• What is the reimbursement for a level 1 billing by Medicaid?

6

$12.28

Non-Emergent Conditions Defined

• Any condition that

can wait for up to

24 hours to be

seen by a provider

• 8% from 2009

and 2010

7

“Non-emergent conditions”

• Retrospective denials for:

– Chest pain

– Shortness of breath

– Hemorrhage in pregnancy

– Sudden loss of vision

– Gallstones

– Diverticulitis

– Cholecystitis

– Asthma

– COPD

– Sprains/Strains/Burns8

Legal Issues: EMTALA

Rep. Peter Stark, D-CA

• Passed in 1986

• Required– Medical Screening

– Evaluation to determine if an emergency medical condition exists

– Stabilization such that no material deterioration is likely to occur

9

Prudent Layperson Prudent layperson, who

possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition

(a)placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy,

(b)serious impairment to bodily functions, or

(c) serious dysfunction of any bodily organ or part.

RCW 48.43.005(12).

10Included in the ACA in all States in 2014

Parties Involved• HCA

– Jeffrey Thompson

– Doug Porter

• WA ACEP

– Team of 3

• WSHA

• WSMA

11

Three Visit Rule Process

HCA Policy

12

Regulatory Media

Legal

Legislative

CMSCongress

Patient Advocates

Lay Public

Victories Along The Way?• November 10, 2011

• Stay granted by Superior

Court Judge for Failure to

Follow Proper Rulemaking

• HCA halted implementation.

– Prior denials halted

– No lost payment

13

Center for Medicare and Medicaid Services

• Met with Marilyn Tavenner,

acting director of CMS

• Met with Steve Cha, MD, head

of Medicaid

• “We agree with you in

principle, but we prefer to

have you work it out at a

state level at this time”…

14

Return to the TableFocus on Priorities• Improving health outcomes

• Preserving Prudent Layperson

Protection & access to Emergency

Services

• Coordinating care for the highest

utilizers

• Meeting the State’s budget

requirements

15

We Won!• Governor Suspended Three

Visit Limit policy April 1st, 2012

• Moved forward with

alternative plan in budget

proviso on April 10th, 2012

• June 15th, deadline for

implementation

16

17

The Seven Best

Practices

Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

A) Electronic Health Information

Goal: Exchange patient

information among Emergency

Departments

• Identify frequent users

• Get access to treatment plans

• Use in providing care

• Exceptions for CAHs with

financial burden

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Emergency Department Information Exchange

EDIE Alert with Care Plan during MSE

Case Management

Registration to the cloud

B) Patient EducationGoal: Help patients

understand and use

appropriate sources of

care

• Active distribution of

educational materials

• WSHA/WSMA/ACEP

brochure

• Discharge instructions

20

“The Poster” 2.0Not to supplant or interfere with Medical Screening Exam

21

WarningWhat about my Press-Gainey

Scores?

22

C) Patients Requiring Coordination (PRC)

“Superutilizers”Goal: Ensure hospitals know when they are

treating a PRC patient and treat accordingly• PRC clients = frequent ER users, MOST VULNERABLE. 80%

concomitant mental health & drug & alcohol issues

• Receive and use client list

• Identify patients on arrival

• Develop and coordinate case management programs

• Use care plans

23

D&E) PRC Client Care Plans and Follow up

Goal: Assist PRC clients with

their care plans

• Contact the PCP on arrival

• Appointment within 72 hours when

appropriate

• If not needed, notify PCP of visit

• Relay barriers to care

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All clients:

3-4%1-2%

ED Care Plan Standard• Header Information

– Date Plan First Created– Date Plan Last Updated

• Security Alert

• Pain Contract and Scheduled

Prescribing

ED Care Plan Standard

• Primary Care Provider and

Specialist• Past Medical and Surgical History• Substance Use and Abuse History• Mental Health Conditions

Care Plan StandardOptional (Phase 2)

• Optional sections, may be made mandatory

later.

• Barriers to Care Delivery• Radiation Alert• Overdose Alert• Special Care Recommendation• Details

F) Prescription Monitoring

Goal: Ensure coordination of

prescription drug prescribing practices

• Enroll providers in Prescription Monitoring Program:

electronic online database with data on patients

prescribed controlled substances

• Target enrollment for ER providers :

– 75% by June 15, 2012

– 90% by December 31, 2012

28

Prescription Monitoring Programs

• Game Changer

• 49 out of 50 states have this, largest network

shares across 25 states

• In WA, 96% of ED providers registered

• “REGISTERED” does not equal “USES”

• ACEP against mandated use…

but imagine Push not Pull, No Bias, part of the

EDIE

G) Use of Feedback Information

Goal: Review reports, ensure

interventions are working

• Designate ER leader and quality manager

to receive, review, and act on utilization

management reports

• Involve executive-level leadership 30

Decrease in ED Prescriptions per month written to PRC Clients in One Hospital

6 Vs. 108, Pills per shift ?

“Dr. Feel-good” Vs. “Grumpy”Find the Best Practice

IN GOD WE TRUST….

All others Bring

Data!

33

Reduced ED visits by 9.9%

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

3032343638404244464850

Rate of ED Visits per 1000 Medicaid Clients

34

Reduced number of visits by frequent clients by 10.7 %

35

Reduced visits resulting in a narcotic prescription by 24%

36

What does that mean for patients?

37

MVA Vs. Overdose Deaths

Overdose Deaths in WA State

Reduced low-acuity visits by 14.2%

38

Savings of $33.65 million

were achieved.

39

What Did We Learn As Doctors?

• Advocacy is a process

• Relationships are critical

• Teamwork is more effective

– Can be difficult

– Temptation can be the enemy

40

?

My Time As Chapter President

Find your Allies

Focus on your Priorities

Believe in Win-Win

Questions?

42