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
18
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
24
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
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