Program For Poor Cuts ER Visits By Half

A federal demonstration project that expanded safety net coverage for some of California's poorest residents also dramatically cut the number of hospital emergency room visits among certain segments of that population.

That was the conclusion of UCLA researchers who have recently reported on the multi-year project, known as the Health Care Coverage Initiative. It expanded coverage in 10 California counties to include more than 236,000 residents. 

The initiative, part of a 1115 waiver project funded by $540 million from the Centers for Medicare & Medicaid Services, ran from September 2007 to August 2010. Most of the enrollees were later moved into the Low Income Health Insurance Program, an early expansion of Medi-Cal coverage under the Affordable Care Act.

Enrollees in Medicaid or similar public programs have a tendency to use the ER far more than those with private coverage. According to some studies, Medicaid payments cover as much as half of the costs for all ER visits that were not medically necessary.

The reduction of ER utilization in the HCCI initiative was linked specifically to the use of medical homes – a primary care provider or clinic to which the Medi-Cal enrollee was assigned to receive their care.

According to the data compiled by UCLA, there were 606 emergency room visits without hospitalization – a suggestion of the seriousness of the underlying medical condition was – per 1,000 patients in the population who were not assigned to a medical home. Among those with a medical home for the three years of the demonstration project, the rate dropped by more than half, to 295 ER visits without hospitalization per 1,000 patients.

“The basic assumption is that if you provide people with primary care, which includes preventative services, you are going to reduce down the line the visits for urgent services,” said Nadereh Pourat, director of research for the UCLA Center for Health Policy Research.

The study, a 296-page examination of the outcomes associated HCCI program that was published on Wednesday, contradicts the finding of a national report issued earlier this month by the National Bureau of Economic Research. NBER researchers concluded that when patients were newly enrolled in a Medicaid program in Oregon, they were 40% more likely to use hospital ERs for care, with many visits non-emergent in nature.

Pourat noted that great diligence was exercised to try and keep the HCCI participants out of the ER when they sought medical care. Providers willing to provide a medical home were sought out in order to ensure there were enough to service the population. And HCCI participants were educated by caseworkers for the participating providers about when using a hospital ER is appropriate.

“You have to change people's perceptions and habits. Some people have learned that you could sit in a clinic for hours to get a prescription filled, and would decide to go to the ER and get it over there,” she said. 

Cutting down wait times for basic services were addressed, as well as educating patients on when it was best to use the ER. HCCI participants with mental health issues or other obstacles that may have been prompting them to habitually seek ER care in the first place were also counseled appropriately.

In some counties, hospitals and clinics also assigned caseworkers to specifically focus on cutting down ER visits for HCCI enrollees. Kern Medical Center in Bakersfield specifically assigned a caseworker at the hospital to intercept HCCI enrollees and steer them back to their medical home when necessary.

In some counties, payments were denied for non-emergent ER visits.

Repeat visits to the ER were also reduced significantly. Among those with a medical home during their entire enrollment in the program, only 1.7% visited the ER more than once. That compares to 3.4% who made multiple ER visits who did not have a medical home, and 4.6% of patients who occasionally had a medical home who had multiple ER visits.

The rates of ER visits also dropped among those HCCI participants with chronic conditions such as diabetes and asthma, although not as dramatically as compared to the entire patient population.

Overall hospitalization rates also decreased when HCCI participants had a medical home. 

Just 1.6% of those with a medical home for the entire three years had a hospitalization, and only 0.3% were hospitalized more than once. The hospitalization rate among those without a medical home was double that at 3.2%, with the rate of multiple hospitalizations at 0.6%. It was even higher among those who were in a medical home for part of their enrollment period: 4.5% overall, with those hospitalized numerous times reaching 0.9% -- triple that among those with a full-time medical home.