New Report: Decreasing rate of non-emergency ER visits for Arizona Medicaid members

The number of Medicaid members in Arizona who utilized emergency departments for non-emergencies decreased between 2012 and 2017, according to a new report from the Arizona Health Care Cost Containment System (AHCCCS). The report attributes the trend, in part, to efforts led by AHCCCS.

The report used the American College of Emergency Physicians’ facility coding model when it categorized emergency-department data. Visits coded as Levels I-III could typically be resolved by a primary care provider or urgent-care physician, while visits coded as Levels IV (e.g. headache, constipation) and V (e.g. suicidal ideations, chest pain) were typically emergency-related.

From 2012 to 2017, the percentage of visits by Medicaid members that were coded as I-III decreased by 8.6 percent.

 

Image: AHCCCS (The report notes that “The large increase in the number of visits and paid amount from SFY 2014 to SFY 2015 corresponds with Medicaid restoration and expansion.”)

 

The trend was also reflected in payment data: In 2017, 77 percent of the total amount paid went toward visits coded as Level IV or V.

 

Image: AHCCCS

 

Notably, the report features a few caveats on the data used for the report. First, AHCCCS warns that the coding system isn’t foolproof, and gives examples of when that might be the case.

“A patient complaining of chest pain could be displaying early signs of a heart attack or may be suffering from heartburn,” the report says. “In this case, a visit to the emergency room would be appropriate even if the visited resulted in learning that the patient was merely suffering from heartburn.”

And 90 percent of the visits that contributed to the 39-percent increase in Level V visits between 2016 and 2017 can be attributed to one hospital system: Banner Health, which may be because of a change in coding.

“According to Banner Health, they adopted new software in March 2016 which assigns the charge code Level based on the hospital resources that were used to treat the ED patient instead of the acuity of the actual diagnosis,” the report says.

Finally, data used for the report didn’t include emergency department visits that lead to inpatient admission, because the emergency-department charges are wrapped into inpatient bills. The report mentions that, if the data could be parsed out and included, it would result in an even higher percentage of visits for true emergencies.

Caveats aside, though, AHCCCS reports an overarching theme of positive progress.

“Overall, AHCCCS members demonstrate a relatively low rate of non-emergency ED utilization, particularly when compared to national averages,” the report reads. “Despite the low percentage of improper ED utilization, AHCCCS continues to work with its contracted MCOs, hospitals, and other providers to further reduce ED utilization for non-emergency use.”

In the report, AHCCCS highlights several initiatives and efforts it launched in recent years to reduce over-utilization of emergency departments. Broadly, it named “incentive payments, integration, and High Needs/High Cost intervention,” and mentioned that “AHCCCS also continues to re-examine reimbursement methodologies to ensure that they do not encourage inappropriate use of the ED.”

The report goes into deeper detail on what could be behind the positive trend, explaining efforts like the value based purchasing (VBP) initiatives that AHCCCS expanded to all of its contracts, one of which focuses on reducing emergency department utilization.

“To encourage this effort, managed care organizations (MCOs) may allow providers to share in savings incurred through reducing unnecessary use of the ED, or otherwise reward providers for meeting preestablished performance metrics related to this utilization.”