Examining financial incentives for PCPs and ER physicians, engaging PCPs in their patients' progress after they leave the ER, and ensuring PCPs' accessibility during and after discharge are some of the ways Wellpoint has reduced ER utilization, explains Karen Amstutz, MD, MBA, and vice president and medical director of Medicaid and senior markets, and Barsam Kasravi, MD, MPH, and managing medical director for state-sponsored programs.
There are some major areas where intervention by providers can lead to a decrease in ER utilization. One of the issues we've looked at is financial incentives in the ER. There are financial incentives for providers in the ER to see members. There is definitely not a disincentive, and we are trying to find the best way to incentivize the ER physicians and PCPs to help get that member in the right setting for their care.
There is a lack of communication to the PCPs on patients. Once they leave the hospital or ER, there is a gap in how that information gets transmitted back to that PCP. Do they know that their patient was in the ER two days ago? Do they know what was done in the ER and how the medications were changed? How did that member get re-linked to their PCP?
There is this lack of coordination outside the office visit. There is a lack of communication and monitoring of the member unless they are seen by a physician in the ER or in the clinic.
At WellPoint, we feel strongly that providers should and are required to have access, and that members should be able to access providers either after hours or the next day. WellPoint conducts two surveys annually to ensure adequate access to primary care. There is the after-hours access survey and appointment access survey. This is an area where PCP offices are contacted by telephone or asked a series of questions to determine if this is in compliance with some of these metrics. Our metrics are that 100 percent of PCPs are offering after-hour responses to members who call, and that 95 percent are providing appointment access in compliance with the health plan's contracts. We mainly look at whether the PCP offices are able to call a member back within 30 minutes of their call if they are not able to be reached immediately. To improve access, we are looking at the barriers that exist when members cannot get that call back.
Source: 27 Interventions to Reduce Avoidable ER Use, November 2010
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27 Interventions to Reduce Avoidable ER Use
This 45-page resource details provider- and patient-focused interventions that target the high numbers of avoidable visits, high and ultra-high utilizers and the sub-populations noted for frequent ER use. Five interventions target these sub-populations: asthma patients, those recently discharged from the hospital, non-network patients, nursing home and assisted living residents and dual-eligibles.
27 Interventions to Reduce Avoidable ER Use is available from the Healthcare Intelligence Network for $167 by visiting our Online Bookstore or by calling toll-free (888) 446-3530.
