The shifting landscape of emergency services

Health Care Current | November 15, 2016

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

The shifting landscape of emergency services

By Sarah Thomas, Managing Director, Deloitte Center for Health Solutions, Deloitte Services LP

I haven’t had to go to the emergency room (ER) in years. Fortunately, when my kids were small (and seemingly had emergencies every other month), we had access to urgent care through our health plan. Even though it has been a long time, I still can clearly recall my past experiences with the ER: long waits, crowded, busy, and lots of families camped out for the long haul.

Who would want all of that if there was an alternative? Fortunately, there are many alternatives: Urgent care centers (UCCs) often offer consumers better access and shorter wait times. And, more and more primary care practices are staying open later, seeing patients in the evening and on weekends.

The proliferation of these alternatives, combined with the expansion of insurance coverage, has led some to question, are people actually using ERs less?

The Deloitte Center for Health Solutions took a close look at ER use among two groups of people that policymakers have followed closely: the uninsured and people with Medicaid coverage. Many hoped that ER use would drop as health insurance coverage expanded, providing people with more options and better access to care.

We found:

  • Growth in ER visit rates (ER visits per 100 population) has generally been slower in Medicaid expansion states than in non-expansion states, particularly over longer time periods (two-to-three years following expansion).
  • Following the 2014 expansions in many states, new Medicaid enrollees reported fewer issues in accessing alternative care settings, including primary care, compared with the uninsured.
  • Markets with a higher concentration of UCCs have lower ER visit rates. UCCs are sparse in markets with higher ER visit rates, most of which have larger uninsured and Medicaid populations. However, more UCCs are accepting new Medicaid enrollees and may be emerging as an alternative to ERs.

ER use is driven by many factors; among them are perceived need for urgent care, severity of the medical condition, availability and accessibility of ER and other ambulatory care, and physician referrals to the ER. However, studies suggest that uninsured individuals might be the most likely to use ERs for non-emergency conditions. What our analysis does not do, of course, is show what potential effect that changes to Medicaid or health coverage policy likely to be debated as the administration changes might have on emergency room use.

ERs can be an expensive care setting for routine or preventive care, since their costs include those for maintaining staff and resource-intensive technologies around the clock. Many people are admitted to inpatient hospital care from ERs, which runs costs even higher. Moreover, most ERs are not set up to provide continuity of care, are not a substitute for a primary care relationship, and often cannot focus on addressing broader social determinants of health.

Under new value-based payment models, including those under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), many health care payers (government and private health plans) and health systems are striving to find ways to lower total cost of care while maintaining high quality. This includes reducing costs through more appropriate use of ERs.

Many states also are trying to reduce preventable ER use among Medicaid enrollees. A few examples of these initiatives are:

  • Investing in preventive care for new Medicaid enrollees, including making sure that new Medicaid enrollees get timely health screenings. Michigan’s expansion program, for instance, requires new members to schedule a preventive health visit with a primary care professional within 60 days of enrollment. 
  • Increasing the number of primary care professionals. Several state health departments are working closely with the federal National Health Service Corps program to fill potential staffing gaps in underserved areas by providing scholarships and educational loans repayment for primary care physicians, nurses, and other health care professionals in these areas.
  • Building community health centers.
  • Targeting ER “super-utilizers” – beneficiaries who overuse ERs. For instance, Washington implemented a statewide patient data exchange system to identify frequent ER users; once identified, state agencies help make primary care appointments for them. The state also increased educational efforts to advise these super-utilizers on what constitutes a true medical emergency. 
  • Enforcing financial disincentives to discourage non-emergency ER visits. States such as New Mexico, Arizona, and West Virginia have either increased or have plans to increase Medicaid enrollees’ ER copayments for non-emergency ER use.

Health plans and health systems looking for strategies to reduce total cost of care under MACRA and other value-based care initiatives could focus on reducing costs and improving outcomes associated with ER use. For health systems, one way to do this is through acquiring or creating joint ventures with UCCs to complement their ER offerings, reduce uncompensated care costs, and avoid putting undue strain on limited resources such as primary care physicians and nurses. Using technology and analytics could also help health systems steer patients to the right care setting.

These Medicaid strategies and programs could be instructive. Another area worth considering is the extent to which primary care practices, especially those that are patient-centered medical homes, will invest in providing 24/7 access, offering another good alternative to the ER with even better care continuity than UCCs.

There likely will always be a need for emergency services in the health care system. Serious health conditions can show up at any time – kids can suffer from severe asthma attacks and adults can have strokes and heart attacks where they need emergency services. But, having alternatives is also a good thing. Sometimes kids just sprain their wrists or you need a quick fix for a migraine. As access to preventive services such as screenings and timely access to primary care and settings such as UCCs increase, we could see more appropriate use of both settings.

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Implementation & Adoption

Hospital readmissions decline among Medicare Advantage beneficiaries

Hospital readmission rates for Medicare beneficiaries enrolled in Medicare Advantage (MA) plans have declined an average of 0.8 percent per year over five years, according to a Health Care Cost Institute (HCCI) report.

The report reviews hospital-wide readmissions and 30-day readmission measures for:

  • Acute myocardial infarction (AMI)
  • Heart failure
  • Chronic obstructive pulmonary disease (COPD)
  • Pneumonia

All of the readmissions measures saw decreases over the five-year period.

Hospital readmission rates varied across diagnoses from 2010 to 2014. Though declining, cardiac-related admissions have the highest readmission rates overall. Heart failure readmission rates declined from 17.06 percent to 15.64 percent. The largest overall decrease was among AMI readmissions, down from 12.41 percent in 2010 to 11.30 percent in 2014.

Analysis: Readmissions rates are often used as an indicator of the quality of care during the initial hospitalization as well as any related follow-up care. The US Centers for Medicare and Medicaid Services (CMS) gauges MA plan performance using the star rating system and one of the star ratings measures is all-cause readmissions. On the traditional Medicare side, CMS uses hospital readmission measures to show hospital quality in the Hospital Compare database. Moreover, the Affordable Care Act (ACA) created penalties for hospitals with high readmissions rates. Under the Hospital Readmissions Reduction Program, hospitals’ payments are lowered for higher rates of 30-day readmissions for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and coronary artery bypass graft surgery.

(Source: HCCI, “Medicare Advantage Health Care Utilization: Hospital Readmissions,” November 2016)

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Study: One-third of office-based physicians share patient information electronically

According to the US Centers for Disease Control and Prevention (CDC), the majority (77.9 percent) of US physicians used certified electronic health records (EHR) systems in 2015, but only one-third of those physicians electronically sent, received, integrated or shared patient health information that year. Moreover, only 8.7 percent of office-based physicians performed all four activities.

Using data from the 2015 National Electronic Health Records Survey, the CDC report also highlights variation in the electronic sharing of information at the state-level. Usage of EHRs for each of these functions varies by and within each state. For example, more physician offices in Arizona send patient information electronically to other providers than the national average (56.3 percent). Physician offices in Minnesota (55 percent), Oregon (59.2 percent), and Wisconsin (65.5 percent) have higher than national rates of electronically receiving patient health information from other providers.

Analysis: Interoperability among certified EHR systems may depend on these four key aspects, and interoperability is a key issue getting attention under MACRA. Deloitte’s 2016 Survey of US Physicians found that the majority of physicians surveyed hold relatively negative perspectives on some aspects of EHRs. Indeed, three out of four physicians believe that EHRs increase practice costs, outweighing any efficiency savings, and seven out of 10 physicians think that EHRs reduce their productivity. Moreover, physicians are less likely to think that EHR capabilities support clinical outcomes than they did in the 2014 survey. MACRA emphasizes interoperability, which could improve the functionality of EHRs over time.

(Source: Jamoom & Yang, “State Variation in Electronic Sharing of Information in Physician Offices: United States, 2015,” CDC, October 2016)

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On the Hill & In the Courts

CMS finalizes Outpatient Prospective Payment System rule, including site-neutral payment provision

Earlier this month, CMS finalized the Outpatient Prospective Payment System (OPPS) rule for 2017. The OPPS is how Medicare pays for hospital outpatient services in most hospitals (excludes critical access hospitals). The new rates will take effect on January 1, 2017.

CMS finalized the site-neutral payment policy established in the Bipartisan Budget Act of 2015. The provision is intended to close a regulatory loophole that pays hospital-affiliated clinicians’ offices as hospital outpatient departments, a rate that is typically more than would go to clinicians’ offices. Beginning on January 1, 2017, provider-based departments (PBDs) that are not on the main campus of a hospital or health system – and began furnishing services on or after November 2, 2015 – will no longer be eligible for payments under the OPPS. Instead, hospital- and health system-affiliated PBDs will be paid the same way as independent PBDs – under the Medicare Physician Fee Schedule. Exclusions to this policy are for services at dedicated emergency departments (even if they are off hospital campus) and hospitals that have moved their PBD offices due to natural disaster or renovations.

In addition to the site-neutral provision, the rule also finalizes several other updates:

CMS expands diabetes prevention demonstration to all Medicare beneficiaries

Earlier this month, CMS announced that it will expand eligibility for the Medicare Diabetes Prevention Program (MDPP) to all Medicare beneficiaries by January 1, 2018. Developed by the YMCA and piloted by the CMS Innovation Center, the MDPP is the first preventive service model to become eligible for expansion in the Medicare program.

According to CMS, expanding the MDPP will decrease the incidence of type 2 diabetes in Medicare beneficiaries. The MDPP recruits participants diagnosed with pre-diabetes and provides them with weight control services – including physical activity and dietetic supports – in community-based and health care settings. CMS says that the program improves results for many participants:

  • More than 80 percent of participants in the pilot model attended at least four support sessions.
  • People who attended at least nine sessions lost an average of 5.17 percent of their body weight. 
  • On average, participants lost 4.73 percent of their body weight and saved the program an estimated $2,650. These savings cover the cost of the program.

Approximately 26 percent of the Medicare-eligible population has diabetes. Medicare spending on these 11 million individuals is approximately 86 percent ($7,300) higher per beneficiary per year than spending on Medicare enrollees who do not have diabetes.

The MDPP benefit will be a 12-month consecutive program. Beneficiaries will receive 16 weekly core sessions over the first six months, and at least six monthly core sessions over the second six months. Continuing maintenance services will be available after the first year to participants who lose at least five percent of their body weight. CMS is requesting comment on several components of the rule, including potential eligibility for telehealth providers, policies on monitoring and enforcement actions, and applicable quality reporting measures.

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Around the Country

Massachusetts Medicaid waiver revamps payment and delivery system

The Massachusetts 1115 Medicaid demonstration recently approved by CMS will extend the state’s Medicaid demonstration, MassHealth, for five years with $52.4 billion in funding. The demonstration will now run until June 30, 2022 and will keep the state from losing nearly $1 billion a year in federal funds. MassHealth serves 1.9 million enrollees.

Under the waiver, Massachusetts will implement a statewide accountable care organization (ACO) pilot starting in December. Massachusetts will move Medicaid payment from a fee-for-service model to one led by ACOs. The waiver also authorizes $1.8 billion in Delivery System Reform Incentive payments (DSRIP) funding to help pay for the shift to ACOs. Providers will be able to choose from three models that aim to integrate care, increase provider coordination, and improve patient experience.

DSRIP funds will allow ACOs to invest in several community initiatives: social determinants of health, behavioral health, and long-term services and supports. For example, individuals who suffer with substance abuse problems will have an expanded system of community services available for treatment and recovery. Addressing the opioid addiction crisis is also one of the goals of the Medicaid waiver, according to a statement released by Governor Charlie Baker last week.

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NASHP proposes policy alternatives for the CHIP program

Funding for the Children’s Health Insurance Program (CHIP) will expire in September 2017. While the ACA requires Medicaid expansion CHIP programs to maintain eligibility levels for children through 2019 if federal funding is halted, this is only required if funds are available. Now, state policy leaders, such as the National Academy for State Health Policy (NASHP), are exploring options to maintain benefits and service levels to the CHIP population.

NASHP proposes several options:

CHIP provides comprehensive health coverage to children and families with low to moderate incomes. The program is funded jointly by states and the federal government. Most children get their health insurance through employer-sponsored insurance plans from their parents (36.9 million) or through Medicaid (30.6 million). But, 8.1 million children get coverage through CHIP, and another 1.1 million through the exchanges. And, 4.5 million children are uninsured.

Alternatives to the CHIP program would likely face issues of affordability and funding, because CHIP has been deeply subsidized. According to NASHP, options to address affordability include using CHIP funds to subsidize exchange coverage, creating children’s coverage demonstration programs, or fixing the “family glitch” – a loophole in eligibility for financial assistance on the exchanges.

Analysis: It is unclear what the change in administration might mean for the future of CHIP funding or exchanges. CHIP was passed under a Republican Congress, and it is structured as a block-grant program, which is what President-elect Trump has indicated he would like to do with Medicaid funding (see the November 10, 2016 Special Edition Health Care Current). Moreover, the House Republicans said in the “A Better Way” platform that their plan would minimize disruption by continuing federal support for CHIP at historical rates. However, the plan also calls for repealing the ACA’s enhanced federal medical assistance percentage (E-FMAP) of 23 percent.

(Source: Maureen Hensley-Quinn, Anita Cardwell, and Trish Riley, NASHP, “Potential Options and Policy Questions for Improving Exchange Coverage for Children,” September 2016)

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Breaking Boundaries

Health systems tackle the social determinants of health to reduce readmissions and improve outcomes

As the transition to value-based care continues, many hospitals, health systems, and health plans are coming up with innovative ways to address health in communities before people get sick enough to visit or be readmitted to a hospital. While awareness of the social determinants of health is not new, innovators in the health care system are finding ways to align incentives and target areas such as food insecurity and housing instability to improve the health of their communities.

An innovation center out of MN has developed resources – patient information and solutions to challenges around stable housing, job searching, and substance abuse issues. The engine sends a note to patients’ EHRs to alert and involve care managers and physicians.

In Pennsylvania, the Lehigh Valley Network is employing physician assistants to provide medical care to the community’s homeless population, hoping to reduce ER use in this high risk population. And, as described in the My Take above, many health systems are striving to find ways to lower total cost of care while maintaining high quality, which includes reducing costs through more appropriate use of ERs. Social workers help patients take care of nonclinical challenges that get in the way of their health, such as paying their utility bills. The program also helps to connect uninsured people to Medicaid. The program reduced the community’s 30-day readmission rate and decreased the number of uninsured in the community. The program is placing social workers in the ER to identify people who visit the ER at least five times in four months. These patients have a lot on their mind, such as worrying about shelter and where they can afford groceries. This makes it hard to plan ahead with medical appointments. The social workers help them develop a plan, organize transportation, and secure childcare. In the first four months, ER visits by some of these patients dropped by 68 percent, and the cost to care for them fell from $1.5 million to $440,000.

Other hospitals around the country are partnering with US Department of Agriculture and schools in their communities to address food insecurity. Programs like the Summer Food Service Program provide funding to serve nutritious meals to children and teens during the summer when they do not have access to school meals or arrange for free healthy meals to be served in hospital clinics and cafeterias, recreation centers, and parks.

Analysis: Factors outside the health care system influence our health and well-being – termed the “social determinants of health.” However, few organizations have been able to “crack the nut” in figuring out how to measure, track, and link community and clinical services to effectively make a difference in improving health outcomes. Even fewer fully understand whether it is their role to do so in the first place. Recognizing this, CMS has announced a program to provide $157 million over five years to 44 providers to act as “bridges between clinical and community services,” with pilots set to begin in early 2017. Incentives under alternative payment models may fuel more pilots like these as well as dissemination of successful strategies.

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