Saturday, May 16, 2015

Emergency Room Overutilization

It's no secret that Americans are overusing emergency rooms and it's only destined to get worse. And Washington state's Medicaid program, according to this New England Journal article, is ground zero.

Alarmed by rising rates of costly emergency visits, the state decided to stop paying for certain emergency room diagnoses that failed to meet the definition of a true "emergency." The state's governor stepped in at the last minute to put a hold on the program.

According to the authors, the problem is twofold: 1) an inability of "prudent laypersons" to safely discern which symptoms comprise a "true emergency" versus those symptoms that can wait, and 2) a shortage of alternative care settings, especially primary care.

The Disease Management Care Blog agrees but also points out that not paying for these diagnoses will financially penalize otherwise "innocent" emergency providers who cannot control the utilization of their services.  That threat will be enough tempt emergency rooms to turn to "creative" upcoding to justify payment. The result will be a billing arms race that will contribute to the already high administrative costs for the Medicaid program as well as the hospitals.

In the meantime, there are studies like this that demonstrate that population health management (PHM) telephonic advice lines can be used to help patients decide whether they have a true emergency or not.

The Governor did the right thing.  It'll be interesting to see what happens next and if Washington will consider using telephonic triage.

Image from Wikipedia

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