Hospitals starting to plan for influx of emergency cases come 2014


by Ed Sealover

Source: Denver Business Journal

Hospital emergency rooms — already bursting at the seams — may be pushed past the breaking point as 16 million more Americans are put onto Medicaid rolls when federal health care reform kicks in fully in 2014, a new study says.

ERs nationwide could have 848,000 to 901,000 additional visits every year because of the newly ensured, posits The National Center for Policy Analysis (NCPA), a Dallas-based public policy research organization. That could lead to longer waiting times and more use of ambulances, among other things, the study said.

Colorado hospitals are starting to figure out how to deal with that. The Medical Center of Aurora (TMCA) has begun a program that refers more Medicaid and Medicare enrollees to primary care doctors, and Memorial Hospital in Colorado Springs is seeking to divert more care to federally qualified, low-income health centers.

“I think there’s going to be an increasing population that seeks care [in emergency rooms]. We don’t have an exact prediction, but I think everybody believes that’s going to happen,” said Dr. Dennis Waite, TMCA chief medical officer. “That’s got everybody worried about: If we have this relatively high influx, where are they all going to go?”

The Patient Protection and Affordable Care Act (PPACA), signed into law in March 2010, mandates that all Americans have health insurance by 2014. To do so, it increases the eligibility levels for Medicaid, and some 16 million people are expected to be added to its public rolls.

Hospitals have viewed the moving of patients from being uninsured to being covered by Medicaid as positive, ensuring that they have some income stream from their poorest patients. The Colorado Hospital Association worked with former Gov. Bill Ritter to impose a per-patient fee on hospitals to pay to get more uninsured patients registered for the program.

But the NCPA study released in January also noted that, according to the National Center for Health Statistics, Medicaid enrollees are more likely than privately insured or uninsured individuals to visit a hospital emergency room and to use it multiple times in a year. That means that while hospitals may be reimbursed in 2014 for indigent patients, those patients are likely to come back more frequently and clog ERs.

Enrollees frequent hospital rooms because fewer primary care doctors accept Medicaid patients, as the fees Medicaid pays health care providers are 59 percent of what private insurers pay on average nationwide, said Devon Herrick, a health economist with NCPA. Conditions that send insured families to a doctor’s office leave Medicaid recipients nowhere to turn beside hospitals that are required to treat everyone entering their ERs.

In 2007, Herrick said, 32 percent of Medicaid enrollees used an emergency room — nearly twice as many as the 17 percent of privately insured individuals or 20 percent of uninsured individuals who sought ER services. Meanwhile, 15 percent of Medicaid recipients made two or more visits to the ER that year, triple the 5 percent of privately ensured residents that did.

Overall, 32 million Americans are expected to be insured by 2014 because of PPACA — half through private markets, many of them subsidized, and half through Medicaid.

“I think people are just beginning to realize ... we don’t have the physicians to cover 32 million more people who will want to double their consumption of medical care,” Herrick said. “If you have less access to a primary-care provider ... the default use [of your insurance] is the ER.”

Some health care officials aren’t convinced the NCPA study’s conclusion is correct. Dr. Mark Earnest, an associate professor at the University of Colorado School of Medicine, argued that because most of the people who will be going onto Medicaid are uninsured now, many already are frequent ER users who won’t change their habits to show up more.

“We’re going to see patients we’re already seeing who are uninsured, except they are going to have Medicaid,” said Peg Burnette, CFO of Denver Health, which had 63,000 emergency room visits in 2010. Denver Health already has established a program to get Medicaid patients to see physicians in its network of primary-care clinics rather than coming to the ER for standard health care.

Regardless, several area hospitals are making plans to see more patients or to redirect them to prevent long waiting lines.

TCMA is signing primary-care doctors to employment contracts, hoping that’ll lead those doctors to care for more of the patients now using the ER as their first source of medical care. The hospital will take over accounting, billing and personnel oversight for the practices and will supply them with electronic medical records to free up their resources to deal with more patients, including Medicare and Medicaid recipients, Waite said.

TCMA also has begun arranging for patients without primary-care doctors to be seen by doctors at a nearby clinic when they leave, hoping they’ll begin going to see those health care providers before they use the ER.

Memorial Hospital of Colorado Springs, which treats 100,000 people per year in the state’s busiest emergency room, has brought in officials from nearby Peak Vista health clinic to talk to non-emergency patients before they even leave its ER, said John Suits, director of business development and government relations.

Officials say it’s helped reduce the number of repeat non-emergency patients, but they hope that the federal and state governments will do something to educate the newly insured in 2014 about non-ER health care options, he said.

“We won’t do anything different as far as the delivery of the care. But we will certainly have to ramp up with it comes to [full-time employees],” Suits said. “We will look at different ways to triage the patients into the system.”

Some hospitals are preparing for more patients by expanding their facilities. St. Anthony Central Hospital is moving to a new Lakewood facility in July that includes an additional 13 emergency department exam rooms and is designed for more efficient patient flow. It’s also designed to give the hospital the ability to expand the emergency department in a way “that will be economical and have minimal disruptions to existing structures,” said Bev Lilly, public relations manager.

And some hospitals are studying current ER procedures to learn how to make them more efficient.

Rocky Mountain Hospital for Children in Denver is examining lab turnaround times, patient-flow management and even the time it takes to get patients to radiology to see if it can tweak anything to move patients through more quickly, said Matt Sogard, chief operating officer.

“None of it’s really rocket science,” he said. “We just have to focus on that process and trim out wasted steps.”

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