Florida Emergency Department Florida Emergency Department CollaborativeCollaborative

June 8, 2011June 8, 2011

Presented by:Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical OfficerMargaret deHesse, RN, BSN, Executive Director State and Corporate Services

Overview

Goal of the Emergency Department (ED) Collaborative

Objectives of the ED Collaborative Characteristics of ED populations National and Florida ED utilization ED utilization analysis – HMO/PSN Key drivers of inappropriate ED use Conclusions Timeline

Goal of the ED Collaborative

Reduce unnecessary ED utilization among Florida Medicaid managed care recipients through a collaborative effort

Effectiveness of current Florida-specific ED strategies

Challenges in managing consumer and provider

behaviors resulting in inappropriate ED utilization

Need to address ED utilization at a systems level

Goal of the ED Collaborative

Direct managed care consumers to seek care in the most appropriate setting and to reduce ED use in non-emergent situationsLeadership required to direct the effort

Identify the priorities

Identify the stakeholders

Identify possible solutions/strategies

Characteristics of ED Populations

National Hospital Ambulatory Medical Care Study – 2006 Emergency Department Summary, DHHS, CDC, August 2008. Medicaid consumers visit the ER more frequently than

individuals with any other source of payment

Infants under twelve months had the highest utilization

Persons aged 75 and older were the second highest followed by persons living in nursing homes and homeless persons

Black persons visited the ERs approximately twice as often as white persons, regardless of age

National ED Utilization

Florida’s overall ED utilization rates have been consistently comparable to national averages.

Classification of ED Visits

NYU Algorithm:Developed with advice of panel of ED and Primary

Care Physicians (PCPs) after examination of nearly 6,000 full ED records by panel

Grouped ED visits into categories: Non-emergent Emergent Primary Care Treatable Emergent Preventable/Avoidable Emergent Not Preventable/Avoidable

Classification of ED Visits

NYU ED Classification Algorithm:

Florida Medicaid ED Utilization Rates - Methods and Findings

Participating plans included Reform HMOs and PSNs in Broward, Baker, Clay, Duval, and Nassau counties

State fiscal year (SFY) 2010 Claims Data was employed in all ED analyses

Applied NYU algorithm to SFY 2010 ED Visits

ED utilization analysis includes results reported by: Product type by Adult and Child

Top 10 Diagnoses by Adult and Child

Gender

Age

Non-Emergent/PCP Treatable/Preventable ED Visits Demographics

Demographic Categories

Non-Emergent, PCP Treatable, Preventable ED Visits

Number of Visits Percentage of Visits

GenderMale 30,299 53.2%

Female 47,763 58.9%

Age GroupAdult 28,451 57.0%

Child 49,521 56.3%

Age and Gender

Male, 21+ 6,073 49.9%

Male, 0-20 24,226 54.2%

Female, 21+ 22,378 59.3%

Female, 0-20 25,295 58.6%

HMO/PSN ED Visits - Adult

Reform HMOs Reform PSNs

43% (10,588)Emergent Not

Preventable/ Avoidable ED Visits

57% (13,949)• Non-Emergent ED Visits• Primary Care Treatable• Preventable/Avoidable

43% (10,902)Emergent Not

Preventable/ Avoidable ED Visits57% (14,502)

• Non-Emergent ED Visits• Primary Care Treatable• Preventable/Avoidable

HMO/PSN ED Visits - Child

Reform HMOs Reform PSNs

44% (19,740)Emergent Not

Preventable/ Avoidable ED Visits

56% (25,528)• Non-Emergent ED Visits• Primary Care Treatable• Preventable/Avoidable

44% (18,629)Emergent Not

Preventable/ Avoidable ED Visits56% (23,993)

• Non-Emergent ED Visits• Primary Care Treatable• Preventable/Avoidable

Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Adult

Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non-emergent/PCP treatable/preventable.

Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Child

Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non-emergent/PCP treatable/preventable.

Summary of Findings

When evaluating product type (i.e., HMO vs. PSN), there is little to no variation in the percentage of non-emergent, PCP treatable, and preventable/avoidable ED visits for both the adult and child populations

In comparing the top ten diagnoses of non-emergent, PCP treatable, and preventable/avoidable ED visits between the adult and child populations three common diagnosis were identified:Upper respiratory infectionsAbdominal painSkin and subcutaneous tissue infections

Key Drivers of Inappropriate ED Use

Consumers Inadequate logistical access to primary care services

Lack of knowledge about when to use primary care, urgent care, and emergency care

Lack of alternatives to the ER for after-hours health care

Lack of convenient or “open” appointments

Lack of access for specialty and behavioral health services

Lack of disincentive for use of the ER for non-emergency conditions

Key Drivers of Inappropriate ED Use

Primary Care Providers (PCPs)Lack of alternative methods to address and treat

emergency call needs

Lack of member/PCP relationship (educational opp.)

Lack or absence of a provider phone message

Lack of incentives for providers to provide after hours care

Key Drivers of Inappropriate ED Use

Managed Care PlansLack of a consistent approach regarding when to use

primary care, urgent care, and emergency care

Lack of timely communication between the ED and managed care plans

Lack of member education on ED use

Lack of timely information about members accessing care in the ED

Key Drivers of Inappropriate ED Use

Emergency DepartmentHospitals treat consumers who present, citing the

federal Emergency Medical Treatment and Active Labor Act (EMTALA) - 1986

Consumers can receive health care regardless of resources or time of day

Lack of incentives for hospitals to reduce ED utilization

Lack of communication with managed care plans and providers

Conclusions

Geographic factors, chronic health conditions, and primary care access are all predictors of ED utilization patterns for Medicaid recipients

Potentially successful strategies include increased access to primary care and managed care interventions

Reducing avoidable emergency care will require greater coordination among EDs, Health Plans, PCPs, and consumers

There is no “gold standard” regarding initiatives to reduce avoidable visits to the ED

Timeline

Florida Emergency Department Florida Emergency Department CollaborativeCollaborative

Questions