Wisconsin proposal would help keep chronically ill out of emergency rooms

MADISON - Last year in Wisconsin, thousands of people visited an emergency room more than seven times each — a stream of bad outcomes for taxpayers, the health care industry and the patients themselves.

To respond, lawmakers voted last week to give hospitals a powerful financial incentive to reduce emergency room costs within the state's Medicaid health programs for the needy.  

The pilot proposal: Work with diabetics and patients with asthma and heart disease to control the health conditions that are landing them in the emergency room. If successful, the proposal could mitigate millions of dollars in unnecessary costs for taxpayers and give patients better lives to boot. 

"It's really creative," said Eric Borgerding, the CEO of the Wisconsin Hospital Association and a supporter of the proposal. "I'm confident it will result in a reduction of emergency department utilization."

The approach: Pay health care providers to prevent bad outcomes and emergency room visits for patients rather than paying them even more to provide emergency room care after a patient has had a bout with asthma, or worse yet, a heart attack. 

The caveat: Gov. Scott Walker's administration wasn't closely involved in the proposal and is still reviewing it, with one top official asking whether the state needs a completely new initiative to accomplish what its existing programs could be doing already. 

Pointing to numbers from the state hospital association, Borgerding and Rep. Joe Sanfelippo (R-New Berlin) said that last year 10,000 Medicaid recipients in Wisconsin used an emergency room more than seven times at a total cost of $52 million. 

Sanfelippo worked on the Medicaid pilot after seeing the success that Aurora Health Care and St. Joseph Hospitals were having with a similar initiative.

"I thought, 'Hey, maybe this is a trend and something we can build on,' " Sanfelippo said of the hospitals' efforts. 

By working with a core group of frequent ER visitors, the hospitals worked to ensure that patients regularly saw a primary care doctor, dealing with challenges ranging from child care and transportation to mental illness. Aurora cut per patient costs by an average of $55,000 within the target group at its St. Luke's hospital and nearly $34,000 a patient at its Sinai location. St. Luke's saw a startling 68% decrease in ER visits and an 80% cut in ER costs among the targeted patients. 

"We think there's a lot of room for expanding this," said Mark Huber, Aurora's senior vice president for social responsibility. 

 Anne Johnson, an emergency room physician for Aurora, gives the example of a patient in her 60s with emphysema and anxiety issues who used to show up at the ER five times a month. 

A team at Aurora that included a social worker looked into the woman's case, working to ensure she got the medicine needed to manage her condition and contacting the woman's niece about her aunt's challenges. 

"Her family member had no idea," Johnson said. 

Today, the woman is coping with her condition much better and only needs the emergency room every six months, Johnson said. 

Sanfelippo's proposal, which was approved by the Joint Finance Committee Thursday, would set aside $2.3 million over the next two years to encourage hospitals and health systems to take similar steps. The provision in the state budget still needs to be approved by both houses of the Legislature and Walker. 

Under the program, hospitals and health systems would get up to $1,000 a year for each frequent emergency room patient enrolled and try to lower his or her ER use and costs. If the health systems prevented ER visits and saved money for taxpayers, the state Department of Health Services would pay half of the savings to the health care provider. 

Sen. Jon Erpenbach (D-Middleton) didn't rule out Sanfelippo's proposal but noted there were other approaches to prevent emergency room use, including expanding the state's Medicaid program to more people. 

"There's a lot of ways to work on over-utilization of the ER," he said. 

State Medicaid director Michael Heifetz was also cautious.

Heifetz acknowledged the need to actively manage Medicaid patients' cases. But he also pointed out that the great majority of patients in Medicaid are already in HMOs, which should be doing at least some of this work already. 

The proposal also lays out in some detail how to add more case management into the state's system, reducing the flexibility for state officials, he said. 

"It's very prescriptive and needs further review," Heifetz said of the provisions.