Program curbs unnecessary trips to the ER

Health reform » Experiment improves care and saves money, health officials say.
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Some Utah Medicaid patients who made unnecessary trips to emergency rooms last year got a letter from the state stressing ER costs and urging them to find a primary care doctor.

If they visited an ER for routine care again, they received a second letter with a list of nearby urgent care clinics. After a third such visit, Medicaid officials placed patients on restricted access, which required them to see a family doctor to get prescriptions filled.

Dubbed Utah's Safe-to-Wait Project, the first year of the experiment is a success, state health officials say, curbing non-emergency use of ERs by 55 percent.

For some patients' care, that translated to an average monthly savings of $156.

It may seem a small sum considering the cost of the project, fueled by a two-year, $503,000 federal grant. But only a fraction -- 3 percent -- of Utah's 137,000 Medicaid recipients participated, and on a grander scale, the project would yield greater savings, Utah Health Department researchers predict.

And at a time when swelling health care costs threaten to consume state and federal budgets, every penny counts, said Gail Rapp, director of the state's Bureau of Managed Health Care.

Money isn't the only object; improved care is also the goal, said Melanie Jorgenson, a state restriction program coordinator.

Seeking care for a nagging headache or sore throat at the emergency room isn't a good way to get comprehensive care, Jorgenson said. "The ER's job is to stabilize you and send you home, whereas a primary care doctor will treat the underlying problem or refer you to a specialist who can."

But many of the jobless and disabled Utahns on Medicaid, a low-income health insurance program, don't have a so-called "medical home," or doctor they trust.

In 2006, the latest year for which Utah Department of Health data is available, nearly one quarter of Medicaid patients' 130,000 ER visits were for non-emergencies. That's on par with the rate at which the uninsured use the ER.

For some, it's a matter of education, and helping them locate an urgent care facility, said Jorgenson. In rural corners of the state that don't have urgent care centers, Jorgenson asks patients with the sniffles to ponder, "Is it safe to wait a few hours or few days?"

Jorgenson's team has long flagged frequent visitors of emergency rooms, placing them on restricted access after more than three non-emergency visits to the ER. Now, thanks to a new computer system paid for by the grant, they can intervene earlier.

Low-income advocates like the program, but would prefer even earlier interventions, connecting patients with a true medical home when they enroll in Medicaid.

"It's great if we're preventing primary care-sensitive visits to the ER, but are we also making sure they're getting good primary care?" asks Lincoln Nehring, Medicaid director at the Utah Health Policy Project.

Health officials only tracked ER visits. Just 11 percent of the patients who received warning letters continued to misuse the emergency room, compared with 24 percent of the control group who continued to do so.

On average, it costs about $120 to see a doctor, compared to $1,200 for a trip to the emergency room, said Jorgenson.

"Patients only see the $6 co-pay[ment] and think, 'The cost doesn't effect me,' " she said. "But in the long run it does, when we run out of money and the Legislature has to cut benefits like dental services."