Emergency department review helps save money, speed care


Washington State's Health Care Authority recently announced that we are making a big difference in improving care and saving Medicaid funds through the implementation of a partnership among the state's emergency departments. Let me explain how we did it and why it's a good thing.

Every hospital in Washington participated this past year in the "ER is for Emergencies" campaign to educate the public on what is appropriate use of an emergency department. The federal Emergency Medical Treatment and Active Labor Act, enacted by Congress in 1986, ensured that everyone has access to emergency services regardless of ability to pay. It requires, by law, that patients receive a medical screening exam when they visit the emergency department. However, some patients visit the emergency department too often. Not very many, but a small percentage of patients actually visit multiple hospitals. They make the rounds in an entire region or metropolitan area and receive duplicate diagnostic tests and duplicate prescriptions, often times for pain medications, in the same day or week. The next week they start the cycle again. In the past we could not track those patients or meaningfully assist in efforts to ensure coordination of care with their primary care provider.

In 2012, the Washington State Health Care Authority, the state agency that administers Medicaid, became interested in controlling costs for a portion of Medicaid recipients who were consuming an extraordinary amount of emergency services. Coordination of care was imperative in ensuring appropriate care while controlling unnecessary utilization. The challenge was figuring out how to curb the inappropriate utilization of an emergency department without risking appropriate access of which everyone is entitled.

Part of the answer was in the development of seven best practices to reduce unnecessary emergency department visits and redirecting care to the most appropriate setting. For example, by tracking the total number of emergency department visits, hospitals now know when a patient has been seen multiple times within a short period of time. This is done through the Emergency Department Information Exchange, a coordinated program between all of the hospitals statewide. The exchange also has the ability to store customized care plans that all emergency departments have access to and are often created in collaboration with the patient's primary care provider. When a patient registers in the emergency department, the exchange alerts the staff that there is high utilization and lets us know whether or not a care plan exists. This enables emergency providers throughout the state to deliver care that is consistent with the established plan of care. (Emergency Department Information Exchange is not to be confused with the medical record, which is still private).

Another best practice is to discourage over prescription of narcotics by tracking physician prescribing practices through the state's prescription monitoring program. Patients with chronic pain greatly benefit when their pain is managed by a single provider. Our compassionate response is to redirect patients, after an appropriate medical screening exam and any necessary treatment that may be needed, toward their primary care provider and ensure that there is a follow up appointment or plan. Although these practices were initially developed out of concern for over utilization of state-funded insurance, all patients benefit from these efforts to coordinate care and ensure appropriate services in the most appropriate setting.

Preventing a repeat emergency department visitor from over-using resources that they don't actually need is more than just a way to save money, it's also kind to them. Some patients, for a variety of reasons, may not navigate the healthcare system well. Gently directing them to either their own provider, or assigned provider, improves their access to appropriate care. Still, no one is turned away, no care has been reduced and money is saved simply because it's not wasted.


Leah Gehri is patient care director of Emergency Services, Critical Care and Trauma at PeaceHealth St. Joseph Medical Center in Bellingham.

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