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Obamacare triggers surge in ER visits

Copyright © 2016 Albuquerque Journal

Old habits die hard.

One of the goals when Congress approved Obamacare in 2010 was that fewer people would use expensive emergency room care for everything from sore throats to urinary tract infections.

It hasn’t worked out that way.

Emergency room visits continue to climb at most of Albuquerque’s major hospitals, with a 10 percent increase at Lovelace and Presbyterian health systems from 2014 to 2015. The number was unchanged at University of New Mexico Hospital. In all, 342,000 patients visited the ERs of the three big medical providers last year.

The increase, also seen nationwide, is partly because people who were previously uninsured put off getting treatment for ongoing health problems. Now that they have insurance cards, they are showing up at emergency rooms because that’s where they were accustomed to going.

And with no or relatively low copays for ER visits by those on Medicaid, even unnecessary ones, there isn’t much of a financial incentive to change.

“Even with insurance now, old habits die hard,” said Dr. John Cruickshank, chief medical officer at Lovelace Health System.

Lovelace and other health care players are trying to thin out their ERs – where care is typically far more expensive – by guiding patients to more cost-effective primary care clinics or other providers. They are hiring more staff and building more clinics to serve more patients outside of the emergency room.

Meanwhile, the Affordable Care Act has brought some financial benefit to Albuquerque’s hospitals: They are seeing a decline in uncompensated care – care provided even when the patient or insurer doesn’t pay for it – because so many more patients are insured in some way.

Hospitals save money

New Mexico was among the states that expanded Medicaid in 2014 as part of the Affordable Care Act. That has meant more than 800,000 New Mexican adults now have health care coverage, compared with 550,000 people before the Medicaid expansion.

Nearly half the states, including New Mexico, may assess copayments for Medicaid patients making unnecessary ER visits.

According to the state Human Services Department website, enrollees do not pay a copay when seen at an emergency room unless the hospital determines it is a nonemergency. In those cases, the patients are charged $8.

Other states are also requiring copays. For example, Indiana imposes a $25 copay for Medicaid patients who make needless trips to the ER.

“When a patient is sick, oftentimes they don’t know what is emergent and what is considered routine,” said Ron Stern, Lovelace health system CEO. “The Lovelace ERs are available to help triage patients and service their needs irrespective of their ability to pay.”

It is not until the service is complete that Lovelace staff address payment, he added.

Nationwide, three-quarters of emergency physicians have seen ER visits surge among Medicaid and other newly insured people since Obamacare took effect, according to a survey by the American College of Emergency Physicians.

“We’re a lot busier. We see way more patients than we used to,” said Darren Shafer, DO, director of urgent and emergent services for Presbyterian’s eight-hospital system. Presbyterian also has 10 primary clinics in Albuquerque.

Those who have Presbyterian plans under the Affordable Care Act are making more emergency room visits than those with other commercial types of insurance, Shafer said. a00_jd_07feb_emergencytable2

Hands down, Presbyterian’s three emergency departments saw the most visitors among the three systems last year: 164,000 people.

Shafer said that, for years, the uninsured patients flooding hospitals racked up millions in uncompensated care for emergency room visits. Many of these patients believed they had no other place to go and some had never gone anywhere else to receive health care.

Thus, the Medicaid expansion has saved Albuquerque hospitals millions of dollars, because hospitals are now compensated for those patients, data compiled by the health systems show. For example, Lovelace saw its uncompensated cost numbers drop nearly 40 percent to $56.5 million last year.

But it benefits both hospitals and taxpayers to limit emergency use to those who need it. That’s because ERs are expensive due to high overhead and increased staffing levels, Cruickshank said.

Navigators can help

Clinical and nonclinical staff say a top priority is to help frequent emergency rooms users – both Medicaid patients and the thousands of previously uninsured who have bought private coverage under Obamacare – find more appropriate care.

Albuquerque’s major health systems are deploying a variety of programs to stem the number of ER visitors in 2016.

They are encouraging those without a regular provider to seek nonemergency treatment at primary or urgent care clinics to deal with conditions that need to be treated quickly.

The wait time is shorter and the visit is less costly.

“Patient navigators in the ER have access to all our urgent care and primary care appointment slots so no one falls through the cracks,” said Shafer. “They (navigators) make sure that those not admitted to the ER have a ride to get to appointments.”

He said everyone who arrives at the ER receives a medical screening exam. But for those whose conditions are best treated in a clinical setting, navigators help them line up seeing a primary care doctor, said Shafer. He said the program began in 2010.

The navigators can also begin the enrollment process that may qualify the uninsured for Medicaid or through the Veterans Administration, he said.

Lovelace billboard advertising that promises an ER patient can be seen in less than half an hour is aimed at patients with serious health conditions, said Cruickshank.

“Our advertising for the Lovelace ERs is an estimated wait time of 30 minutes or less to see a provider” for such patients, he said.

Most of the Lovelace’s 17 clinics in Albuquerque are open regular hours, but the Rapid Care clinic in north Albuquerque offers extended and Saturday hours, as well.

The health system, to accommodate hundreds of potential new patients living near Downtown Albuquerque, also recently opened a primary care facility next to its Medical Center campus. “We didn’t have a primary presence in the area,” Cruickshank said. He believes the new clinic will serve patients discharged from Lovelace’s nearby emergency room who may not have physicians for ongoing medical needs. “We’re already seeing new patients,” Cruickshank said of the new facility, which will offer general surgery and internal medicine services.

Cruickshank says Lovelace is hiring to increase its primary care staff. “Our goal this year is to staff up with 15 to 18 new physicians, three-fourths of whom will be primary carers.”

Meanwhile, Presbyterian is offering other ways to access health care. It has hired “access providers” who can get same-day appointments for people who can’t get in to see their primary care physician soon enough. Also, patients can schedule telephone visits and communicate with providers through MyChart, Presbyterian’s online portal. And it’s hiring more advanced-practice clinicians, such as certified nurse practitioners and behaviorists. These providers aren’t doctors, but they can see and treat patients.

Video visits with health care providers are another option for Presbyterian Health Plan members with mobile data or Wi-Fi access.

Relieving the pressure

Another subset of preventable ER visits involves redirecting people with substance abuse or mental illness.

Steve McKernan, CEO of UNMH, said his ER staffers have made many referrals to Albuquerque Healthcare for the Homeless and First Nations Community Healthsource.

McKernan said Medicaid patients comprised 40 percent of UNM’s ER visitors in 2015; Medicare numbered about 15 percent; the uninsured represented 11 percent of the cases; and commercial insurance made up the rest. “People (with less serious cases) can choose to wait and be seen by a medical provider or head to our urgent care clinic, which is down the hall” from the emergency room, said McKernan.

UNM continues making investments in community-based clinics to take some of the pressure off the ER. It has nine UNM Family Health Centers in Albuquerque. The newest, opened in May, is a North Valley clinic at 3401 Fourth NW. It is UNM Health System’s biggest, featuring 22 exam rooms, a radiology suite, pharmacy and laboratory, and large community meeting room.

McKernan believes insurers, with pressure from Uncle Sam, may at some point start knuckling down on inappropriate or excessive ER use by Medicaid recipients.

“I think there will be a push for them (patients) to do the legwork to find a doctor and not rely on the ER out of habit,” he said.