State aims to curb overuse of emergency rooms by some Medicaid patients

Laurel Andrews

This summer, a new state initiative will seek to curb overuse of hospital emergency rooms by Medicaid clients who are straining the system.

In Alaska, 3 percent of Medicaid clients are responsible for 22 percent of all Medicaid emergency room visits, according to the Department of Health and Social Services . That's 6,512 people categorized as emergency room "super-utilizers," who went to the ER at least five times during an 18-month review period, said project coordinator PK Wilson.

A state review found that one patient used the emergency room 79 times, and the average was 12 visits per person.

The new Alaska Medicaid Coordinated Care Initiative will work one-on-one with willing Medicaid clients to help them coordinate care. It will also identify social barriers - such as transportation or housing issues - that prevent people from accessing non-emergency care.

Emergency rooms visits are much more costly than doctor visits, and overuse of the ER adds to the state's escalating Medicaid's costs, "which are at some point unsustainable," Wilson said. The state and federal governments spend $1.5 billion on Medicaid in Alaska every year.

Wilson described the initiative as an "innovative way to contain costs" that will also help these clients improve their overall health. "It's a win-win," she said.

The 2-year pilot program comes after Alaska was chosen last summer by the National Governors Association as one of six states and one territory to participate in the initiative. The NGA will provide funding for travel and meetings, as well as technical assistance, Health and Social Services director Margaret Brodie testified before the Legislature in February.

Case managers will help clients who chose to participate select primary care providers, a pharmacy, behavioral health facility and hospital where they can get appropriate care, Wilson said.

The case manager will help clients schedule appointments and will be the clients' go-to when they are having medical issues or problems regarding care.

"We understand the health care system is complex," Wilson said. "We think this program can really help people use it immediately more appropriately, and also over the long term."

Case managers will also review medical records to determine whether a patient's repeated visits to the ER were medically necessary or could have been treated differently.

The initiative also seeks to identify social barriers that prevent these patients from accessing health care.

Alaska super-utilizers are concentrated heavily in Southcentral, according to an April report presented by Brodie. More than 4,700 super-utilizers visited emergency rooms in the Southcentral region. Alaska Regional Hospital near the Mountain View neighborhood in northeast Anchorage alone treated 1,069 of these patients.

The reason? "There's not a health clinic there," Brodie said in January . "The closest thing to them is Alaska Regional Hospital, and it happens to be right on the bus route. So that's where they get their primary care."

Roughly 700 super-utilizers were identified in the Interior, around 670 in Southeast, roughly 300 in the "Far North" and around 90 in Southwest Alaska.

Nearly 4,400 were female, and almost 2,000 were children ages 12 or under.

Anticipated challenges to the program stem from Alaska's unique geography, Wilson said, and how to provide care to people living in rural Alaska, where health care options vary.

The program is expected to be in operation by early autumn.

By Laurel Andrews