They float from emergency room to emergency room, knowing just what to say to get narcotics such as Darvon, Oxycontin and Vicodin. And taxpayers pay the bill. The Medicaid clients who are the heaviest users of emergency rooms typically are mentally ill, substance abusers or both, a recent Washington state report shows.
Their cost to the system is less than 1 percent of the $8 billion annual budget for Washington state Medicaid, the state-federal health insurance program for the poor. But they represent a significant problem that may have several solutions, state officials say.
First, the problem: State analysts looked at the top 198 Medicaid users of emergency rooms in Washington. Each of these “frequent fliers” visited ERs more than 30 times in fiscal year 2002. Ninety-nine percent of them took home prescriptions for pain pills. The average number of prescriptions over the year was 42 per client.
Who are they? The list includes a 46-year-old Spokane County woman who, during one calendar year, went to five different hospitals for 119 different emergency room visits – an average of one ER visit every three days. She collected 392 prescriptions that year with her complaints of abdominal pain and depression. Her ER visits cost the state $27,575. Her prescriptions cost $18,154.
That woman was No. 5 on a top 10 list of heavy users of emergency rooms in 2003. The others on the top 10 list came from Snohomish, King, Thurston, Pierce, Yakima and Grant counties.
They are the tip of a very big iceberg. Emergency room use is skyrocketing among Medicaid clients in Spokane County despite an increasing number of community clinics offering care to the poor.
From 1999 to 2003, there was a 42 percent increase in the number of emergency room visits in Spokane County paid for by Medicaid. During the same time, there was a 29.8 percent increase in the number of Medicaid clients.
Emergency rooms are convenient for people who can’t miss work or school to get to the doctor. Some doctors have stopped seeing new Medicaid clients because reimbursements are low. Unlike doctors’ offices, emergency rooms are required, by a 1986 federal law, to medically screen and stabilize all patients regardless of their form of insurance or ability to pay.
Emergency rooms are the most expensive way to get care. Doug Porter, assistant secretary of the state’s Medical Assistance Administration, estimates an emergency room visit by a Medicaid client costs taxpayers $500 more on average than a doctor’s office visit.
That’s because emergency room doctors are paid at a slightly higher rate and hospitals charge a facilities fee. Other fees for tests, supplies and drugs also drive the cost higher. Federal and state taxes pay it all; Medicaid patients pay no co-pays or premiums.
There are several possible solutions to the “frequent fliers” problem.
The state report suggested improving screening in emergency rooms to identify drug abusers. But earlier this year, Spokane hospitals turned down federal grant money that would have funded drug and alcohol counselors in their emergency rooms.
Tacoma General Hospital has participated in the grant program since April. Three chemical dependency counselors have screened about 1,000 injured patients and referred “a few” to brief therapy or treatment, said John Pearson, the Tacoma hospital’s director of social work services.
“I think it’s great,” Pearson said. The counselors “have added a dimension to our care here we couldn’t provide.”
But Spokane’s two busiest emergency rooms, Holy Family Hospital and Sacred Heart Medical Center, turned down the grant because it covered screening only for trauma victims.
“That grant really has no connection with this population and their issues,” said Cathy Simchuk, a Holy Family Hospital vice president. “It did not involve people who came into the emergency department inebriated or under the influence of chemical substances, unless they were there for a traumatic injury.”
With almost 50,000 visits in 2002 – about 130 cases each day – Holy Family had the busiest emergency department in Spokane and the 13th busiest in the state. Sacred Heart handles about 125 emergency cases a day.
“For whatever reason, the Spokane folks declined (the grant for drug counselors), but Yakima was standing in the background, waving their hands in the air and saying, ‘We want it. We want it,’ ” said Ken Stark, director of the state’s Division of Alcohol and Substance Abuse.
For the past 15 years in Idaho, Medicaid clients who abuse the system have been put on “lock-in,” a program in which the client must designate one pharmacy and one doctor to take care of them.
Clients are flagged for lock-in if they overuse emergency rooms, shop around for doctors to prescribe drugs or take a large number of certain anxiety drugs, stimulants or muscle relaxants. About 140 Medicaid clients are on lock-in at any one time, said Idaho Medicaid spokesman Ross Mason in Boise.
“A hospital will know that a client is on lock-in if they scan the Medicaid card. We won’t pay for anything above six annual ER visits for clients on lock-in,” Mason said by e-mail. “Presumably, there might be some exceptions. For example, if this person came in from an automobile accident and was in obvious need of emergency treatment, we would likely go ahead and pay for it. The system does have flexibility but it is on a case-by-case basis.”
Washington has a similar program, called Patients Review and Restriction, or PRR. But it is having trouble recruiting doctors and other practitioners. In the program, a client abusing the system is matched with a health-care provider, who agrees to manage the client’s care.
There are 231 Medicaid clients on PRR in Washington; 61 of them live in Eastern Washington. Another 590 clients have been referred to the program.
There are 180 health-care providers in the program, 47 of them in Eastern Washington.
“The challenge is recruiting physicians,” Porter said. “That’s due to low reimbursement rates. And these are fairly difficult clients.”
Here’s another possible solution: The newly opened Spokane Triage Service, 312 W. Eighth Ave., could help ease the burden on Spokane emergency rooms by taking off their hands people with mental illnesses, emotional crises and addiction problems.
Open 24 hours a day, seven days a week, it is located in what once was a medical clinic within walking distance of both Sacred Heart Medical Center and Deaconess Medical Center. The triage service is a project of Spokane County Community Services and local mental health and detox agencies.
Kelly Hawley, emergency room social worker at Deaconess, said she can ask patients who don’t have medical problems if they’re interested in the triage center’s services. She’ll call a taxi for the people who agree to try it. Deaconess sees about 100 patients a day in its emergency room.
“It’s going to be a great asset to the community,” Hawley said. “It’s filling the gap for people who are experiencing a psychiatric crisis and have no place to get their needs met.”
People also can go to the triage center without a referral, or be referred by mental health crisis workers or law enforcement.
At the center, counselors offer advice. A nurse can prescribe medication. There is a bed for naps in a curtained-off room, a refrigerator stocked with simple meals, a laundry room and a closet full of sweatpants and socks.
The triage center can link people with agencies that can help them while they wait to get into treatment.
In the three months it has been open, the center has helped 373 people, including:
“ A 21-year-old homeless woman, distraught and suicidal because she couldn’t get home for the funeral of a family member.
“ An 18-year-old brain-injured man, brought to an emergency room by police after fighting with a family member.
“ A 30-year-old woman suffering from hallucinations and having trouble taking care of her children.
“ A 42-year-old man, drunk and suicidal, with a history of frequent emergency room use.
John Reamer, director of emergency and trauma services at Sacred Heart, said the triage center is “a step in the right direction.” He said the need outweighs the center’s capacity, however.
In addition, the triage center is not a long-term drug and alcohol treatment program. Getting people into treatment when they’re motivated is a continuing problem because inpatient treatment beds are full. The wait for a treatment bed could be one to three months, said Kasey Kramer, director of Spokane County Community Services.
Bridging that gap, however, could save taxpayers money, state officials say. Drug and alcohol treatment could reduce emergency room costs by 35 percent, according to a recent state analysis. The Department of Social and Health Services is proposing that the next biennial budget include $84.4 million for additional drug and alcohol treatment.
“An ounce of prevention, in this case drug and alcohol treatment, is worth a pound of cure, paying for emergency room services, which really isn’t a cure,” said Stark, director of the state’s Division of Alcohol and Substance Abuse.