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Original Publish Date: September 8, 2015
Since the Affordable Care Act was introduced, nearly 1.5 million additional Washingtonians have gained access to health benefits for the first time. This has resulted in an unprecedented increase in the number of people who now have coverage for preventive and catastrophic care, and has opened the door for this newly insured population to select primary care providers and teams, not emergency rooms, to serve as their health champions and coordinators. For many who have never had health insurance, the emergency room (ER) often served as the entry point into the healthcare system – even when the capabilities and costs of the ER were not necessary. This could not be truer for people with chronic diseases. Overuse of ER services could not have been easier, since ERs are required to assess all people who enter their doors – and 911 Emergency Response Services (EMS) are obligated to respond in person to all calls they receive. If healthcare reform is going to be financially sustainable, one of the many changes required is to dramatically reduce costly and unnecessary EMS calls and ER visits. Easy to say – but not so simple to implement. However, an innovative public/private collaboration between Molina Healthcare, the Research Division of Snohomish County Human Services, and EMS (Everett Fire and Fire District 1) is showing encouraging results.
The majority of health coverage expansion in Washington has been enabled through expansion of the state’s Medicaid program. To help insure that the majority of Medicaid beneficiaries (new and old) receive high quality, cost-effective care, they are given the opportunity to select a Medicaid managed care organization, such as Molina, to coordinate their care so that they have access to the best care, at the most appropriate venue, and with support for prevention and wellness. But as health organizations like Molina work to promote health while simultaneously managing the costs of the public dollars within legislatively approved budgets, it has become necessary to find partners who can help Molina proactively identify and assist those members who have a pattern of overutilizing EMS and ER services.
Reducing Unnecessary EMS Utilization
If one of the greatest opportunities to reduce tax payer supported Medicaid costs is to reduce unnecessary ER utilization, then it stands to reason that the EMS system in each community may possess early information about high utilizers long before managed care organizations and hospitals do. Take the case of “John Doe.” John is a diabetic, and one of Molina’s 550,000 beneficiaries in the state of Washington. In 2012, John contacted the Everett Fire Department Emergency Medical Services (EMS) 48 times by calling 911. Eight of these calls resulted in transport to the hospital for uncontrolled diabetes and were billed to Molina under John’s Medicaid coverage. This meant that Molina was aware of only eight of those calls because they resulted in a bill for transport to the ER. But what about the other 40 calls? In each of these other instances, highly skilled EMS resources were dispatched to John’s house, where they were able to stabilize his blood sugar, review the blood glucose test procedures with him, and encourage him to test regularly to avoid the events that precipitated his call to 911. These 40 EMS visits were not reported to or covered by Molina or Medicaid since there were no “billable” events – even though precious, scarce and expensive EMS resources were expended on each of those 40 calls. Because Molina was unaware of the calls, its available and effective care management and outreach support services were not offered to John—services that might have freed him from his unnecessary reliance on the EMS system, and would have freed EMS responders to focus on the 911 calls that truly required their expertise and scarce resources.
Molina and its Snohomish County partners set out to find a way to improve the health and reduce taxpayer costs of patients like John. In an innovative public/private partnership among Molina, the Research Division of Snohomish County Human Services and EMS (Everett Fire and Fire District 1), an agreement was reached to safely and proactively share HIPAA information between the parties with the express goal of collaborating to improve the health of high needs patients like John. This partnership resulted in a pilot program designed to proactively identify high EMS utilizers who are Molina members. The goal was to connect these high-utilizing members with Molina after just a few calls to 911, so that Molina could provide appropriate referrals, and actively engage in follow up. “High ER utilizers” were defined in the partnership as those Molina members who called 911 three or more times within a month or called four or more times in three months.
Impacts of Intervention and Partnership
The pilot project initially identified members who agreed to utilize Molina’s case management, disease management or other care management services. In John’s case, support was provided from Molina’s disease management team, which helped educate John about his diabetes, provided information on how best to control his disease, and helped him find a primary care doctor in his area. John agreed to receive case management services and participate in a case conference with his Molina health manager, case manager and EMS chief to discuss any barriers to self-care. Together, they developed a plan for John in coordination with his care team. In the six months after John joined the pilot program, his calls to 911 for diabetes-related incidents dropped by 60 percent and his visits to the ER dropped by 100 percent.
John’s case is just one of many in the pilot collaboration between EMS services and Molina that demonstrated a high level of success in reducing unnecessary EMS calls and ER visits simply by sharing information that historically has been invisible to the other. The overall reduction in unnecessary EMS calls for all participating members has yielded a stunning 45 percent decrease over the initial six-month pilot period. The pilot group also experienced a significant reduction in unnecessary ER utilization.
The Snohomish County EMS Pilot Project
Managers from Snohomish County Human Services, EMS and Molina have met regularly to develop ways to identify and enhance the coordination of services and care for those members identified as frequent 911 callers. More specifically, processes were developed for identifying high 911 utilizers; addressing roles and responsibilities of front-line EMS and Molina staff; enhancing interagency communication, collaboration and service coordination; and evaluating the impact of intervention for those identified. Following the successful launch of the initial pilot, the program was expanded. Today, Molina, the Research Division of Snohomish County Human Services, Snohomish County Fire Districts 4 and 7, Everett Fire and the Arlington Fire Department have all come together as partners to help this previously unmanaged population of patients in Snohomish County.
Snohomish County Fire District 1 has also developed its own Community Resource Paramedic program, which targets and supports frequent utilizers and the most vulnerable patients within their catchment area. Building on the interagency collaboration and partnership with these organizations, Molina staff works closely with the Community Resource Paramedic program to address the needs of their shared patients. As a result of this collaboration pilot, both Everett Fire and Fire District 1 now call Molina directly to case conference about members they identify in the field who fall outside of the pilot project catchment area but are at risk and in need of services. This enhanced communication between service providers and Molina has built a cohesive health care community to help prevent anyone falling through the cracks.
Future Opportunities
If a persistent and costly problem such as overuse of EMS and ER services can be solved by collaboration and information sharing as demonstrated in the Molina/Snohomish County pilot, how many more costly healthcare problems might be solved through public/private collaboration?
Visit Molina Healthcare at www.molinahealthcare.com. Visit Snomhomish County Human Services at snohomishcountywa.gov