1. Florida Emergency Department Collaborative June 8, 2011 Presented by: Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical Officer Margaret deHesse, RN, BSN, Executive Director State and Corporate Services

2. Overview  Goal of the Emergency Department (ED) Collaborative  Objectives of the ED Collaborative  Characteristics of ED populations  National and Florida ED utilization  ED utilization analysis – HMO/PSN  Key drivers of inappropriate ED use  Conclusions  Timeline

3. Goal of the ED Collaborative  Reduce unnecessary ED utilization among Florida Medicaid managed care recipients through a collaborative effort Effectiveness of current Florida-specific ED strategies Challenges in managing consumer and provider behaviors resulting in inappropriate ED utilization Need to address ED utilization at a systems level

4. Goal of the ED Collaborative  Direct managed care consumers to seek care in the most appropriate setting and to reduce ED use in non-emergent situations Leadership required to direct the effort Identify the priorities Identify the stakeholders Identify possible solutions/strategies

5. Characteristics of ED Populations  National Hospital Ambulatory Medical Care Study – 2006 Emergency Department Summary, DHHS, CDC, August 2008. Medicaid consumers visit the ER more frequently than individuals with any other source of payment Infants under twelve months had the highest utilization Persons aged 75 and older were the second highest followed by persons living in nursing homes and homeless persons Black persons visited the ERs approximately twice as often as white persons, regardless of age

6. National ED Utilization  Florida’s overall ED utilization rates have been consistently comparable to national averages.

7. Classification of ED Visits  NYU Algorithm : Developed with advice of panel of ED and Primary Care Physicians (PCPs) after examination of nearly 6,000 full ED records by panel Grouped ED visits into categories:  Non-emergent  Emergent Primary Care Treatable  Emergent Preventable/Avoidable  Emergent Not Preventable/Avoidable

8. Classification of ED Visits NYU ED Classification Algorithm:

9. Florida Medicaid ED Utilization Rates - Methods and Findings  Participating plans included Reform HMOs and PSNs in Broward, Baker, Clay, Duval, and Nassau counties  State fiscal year (SFY) 2010 Claims Data was employed in all ED analyses  Applied NYU algorithm to SFY 2010 ED Visits  ED utilization analysis includes results reported by: Product type by Adult and Child Top 10 Diagnoses by Adult and Child Gender Age

10. Non-Emergent/PCP Treatable/Preventable ED Visits Demographics Demographic Categories Non-Emergent, PCP Treatable, Preventable ED Visits Number of VisitsPercentage of Visits Gender Male30,29953.2% Female47,76358.9% Age Group Adult28,45157.0% Child49,52156.3% Age and Gender Male, 21+6,07349.9% Male, 0-2024,22654.2% Female, 21+22,37859.3% Female, 0-2025,29558.6%

11. HMO/PSN ED Visits - Adult Reform HMOsReform PSNs 43% (10,588) Emergent Not Preventable/ Avoidable ED Visits 57% (13,949) Non-Emergent ED Visits Primary Care Treatable Preventable/Avoidable 43% (10,902) Emergent Not Preventable/ Avoidable ED Visits 57% (14,502) Non-Emergent ED Visits Primary Care Treatable Preventable/Avoidable

12. HMO/PSN ED Visits - Child Reform HMOs Reform PSNs 44% (19,740) Emergent Not Preventable/ Avoidable ED Visits 56% (25,528) Non-Emergent ED Visits Primary Care Treatable Preventable/Avoidable 44% (18,629) Emergent Not Preventable/ Avoidable ED Visits 56% (23,993) Non-Emergent ED Visits Primary Care Treatable Preventable/Avoidable

13. Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Adult Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non- emergent/PCP treatable/preventable.

14. Top 10 Non-Emergent/PCP Treatable/Preventable Diagnoses – Child Note: The percents depicted in the graph are the percentage of all ED visits for a given clinical diagnosis that were non- emergent/PCP treatable/preventable.

15. Summary of Findings  When evaluating product type (i.e., HMO vs. PSN), there is little to no variation in the percentage of non-emergent, PCP treatable, and preventable/avoidable ED visits for both the adult and child populations  In comparing the top ten diagnoses of non-emergent, PCP treatable, and preventable/avoidable ED visits between the adult and child populations three common diagnosis were identified: Upper respiratory infections Abdominal pain Skin and subcutaneous tissue infections

16. Key Drivers of Inappropriate ED Use  Consumers Inadequate logistical access to primary care services Lack of knowledge about when to use primary care, urgent care, and emergency care Lack of alternatives to the ER for after-hours health care Lack of convenient or “open” appointments Lack of access for specialty and behavioral health services Lack of disincentive for use of the ER for non- emergency conditions

17. Key Drivers of Inappropriate ED Use  Primary Care Providers (PCPs) Lack of alternative methods to address and treat emergency call needs Lack of member/PCP relationship (educational opp.) Lack or absence of a provider phone message Lack of incentives for providers to provide after hours care

18. Key Drivers of Inappropriate ED Use  Managed Care Plans Lack of a consistent approach regarding when to use primary care, urgent care, and emergency care Lack of timely communication between the ED and managed care plans Lack of member education on ED use Lack of timely information about members accessing care in the ED

19. Key Drivers of Inappropriate ED Use  Emergency Department Hospitals treat consumers who present, citing the federal Emergency Medical Treatment and Active Labor Act (EMTALA) - 1986 Consumers can receive health care regardless of resources or time of day Lack of incentives for hospitals to reduce ED utilization Lack of communication with managed care plans and providers

20. Conclusions  Geographic factors, chronic health conditions, and primary care access are all predictors of ED utilization patterns for Medicaid recipients  Potentially successful strategies include increased access to primary care and managed care interventions  Reducing avoidable emergency care will require greater coordination among EDs, Health Plans, PCPs, and consumers  There is no “gold standard” regarding initiatives to reduce avoidable visits to the ED

21. Timeline

22. Florida Emergency Department Collaborative Questions