Weaning them from the ER

December 5, 2011
| By Pete Daly |
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Repeat customers are a great thing — except at hospital emergency rooms.

People who often visit the ER because they don’t have a primary care physician are adding a lot of cost to the health care system, but just how much money is startling. Spectrum Health opens a new clinic in Grand Rapids today for chronic emergency department users that it says could save commercial insurers plus Medicare and Medicaid more than $15 million in Spectrum Health reimbursements during the first year of operation.

Dr. R. Corey Waller, the medical director of the new Spectrum Health Medical Group Center for Integrative Medicine, said if it were duplicated around the state, it could potentially reduce Michigan’s annual Medicaid costs by $150 million to $250 million.

Medical care provided in the ER can be more expensive than a visit to a doctor’s office, and those ER costs are not fully reimbursed through Medicaid and Medicare, according to Spectrum Health.

The Center for Integrative Medicine, located in a Spectrum Health-owned building at 75 Sheldon SE, has a staff of seven to assess and treat individuals who too frequently use area emergency departments, with the goal of getting them into the traditional primary care system as outpatients. Staff from Network180, the community mental health authority for Kent County, will also provide behavioral health assessments and treatment plans at the center.

The center is in response to a pilot project in 2008 by Waller, an emergency medicine and addiction specialist. During that year, approximately 950 patients were identified as using Butterworth and Blodgett hospital emergency rooms more than 10 times each. These patients were responsible for more than 20,000 total visits and $40 million to $50 million in cost.

According to Spectrum Health, the 950 people were mainly young, healthy people with hard-to-diagnose conditions, psychiatric illness, chronic pain and/or addiction as their major medical issues. The pilot project involving 30 chronic ER patients showed an 85 percent decrease in their visits and close to $1 million in savings.

“This model of care is a win for patients, providers and insurers,” said Waller. “We’re dealing with patients who need an in-depth care plan and a continuum of care that can’t be delivered efficiently in an emergency department setting. It can also free up space in the ED and allow them to deliver care more efficiently. In addition, insurers are paying for primary care for these patients instead of more expensive emergency care.”

The Center for Integrative Medicine will employ enhanced medical management, “aggressive social services” and intensive psychiatric evaluation and treatment, according to a Spectrum news release. The central goal is to develop a care plan for each patient. When treatment is stable and the patient has successfully followed up with a primary care physician, the patient will be transferred into a primary care office.

People visiting ERs more than 10 times a year will be identified as potential patients for the center. New patients undergo a series of in-depth evaluations through multiple visits, which include:

**Full history and physical by a physician trained to care for these patients;

**Mental health evaluation by a mental health professional;

**Comprehensive addiction screening and planning;

**Comprehensive medical social work/case management evaluation and intervention.

Patients at the center will be seen for a three- to six-month period. After successful completion of the program, the patients will be discharged to the ongoing care of a primary care physician.

For the first few months, the center will be evaluating identified high-frequency visitors from Butterworth and Blodgett hospital EDs, then will accept referrals from other hospitals. Meanwhile, Waller will meet with emergency department directors from local hospitals to discuss high-frequency patients visiting multiple ERs who would benefit from being seen sooner.

“Many of the persons who are frequent users of emergency services are already involved with Network180,” said Mark Witte, Network180’s planning director. “This project will improve the health of these patients in a comprehensive way by partnering with Dr. Waller and Spectrum Health to integrate our behavioral health services with this clinic.

“About 54 percent of this population are Medicaid patients and about 16 percent are Medicare patients. It’s historically been hard to get primary care physicians to accept these patients — partly because they have complex medical issues. Because of the center, every one of these patients going to a primary care practice has a full diagnosis and care plan prepared. This approach doesn’t overly stress primary care groups’ resources. It lets physicians focus on working the plan with patients.”

“The pilot program showed we can reduce emergency department visits among this population by up to 85 percent,” said Waller. “I estimate that Medicare and Medicaid could expect a savings of $12-$15 million in charges from Spectrum Health patients alone, which mean $8 million would be saved in one year through Michigan’s Medicaid program. This could mean an estimated one-year savings of $150-$250 million in actual state Medicaid expenditures for these patients if this clinical model was copied throughout the state. This estimation is based on the assumption that emergency department visits would decrease by 50 percent, like they did in our pilot program.”

Waller told the Business Journal that hospital emergency departments are “federally mandated to see anybody who walks in the door.” It is a given that, for the center to succeed in reducing unnecessary ER visits, chronic ER users will have to voluntarily go along with the program.

“We expect 50 percent of the people to come in (to the center) on their own volition. That’s 425 patients right there,” he said.

“Everyone said, ‘Oh, they’re never going to show up. … These patients don’t want help,’” said Waller, but he said in his 2008 project, all of the 30 chronic ER users targeted for the program showed up 100 percent of the time.

Waller said that when a person who has been identified as a chronic ER user shows up in one of the Spectrum Health ERs, a social worker will approach him or her and ask the individual to visit the center. That initial appointment at the center takes about four hours for an in-depth and accurate diagnosis of all social, mental and medical issues that patient has. Evaluation and treatment continues at the center for three to six months, by which point the individual should be ready to make the transition to a permanent primary care physician.

Waller said that about 30 primary care physicians have agreed to take on patients referred by the center. He said those doctors agreed to accept “these typically difficult patients because they will have been seen in the clinic. They will have a plan of care when they arrive at the office.

“I think once we send them patients that show up for their appointments” and have stabilized their problems, “we’ll find that a lot of other physicians jump on board,” said Waller.

When asked how those physicians will be paid, Waller said that only about 7 percent of the chronic ER users do not have any insurance, either private or Medicaid.

“I think most people assume that these are people who don’t have any insurance and no money, but most are actually Medicaid patients,” he said.

Medicaid, he said, “makes it really easy to use the emergency department” because it mandates no co-pays and no barriers to care. “What the patients don’t realize is that they are not getting the same care in the ER as they would at a primary care doctor.”

Waller said another factor that should make the center more appealing is its location: in the heart of the inner city, about one block east of Division Avenue and one block south of Fulton.

The annual cost to operate the center will be about $950,000, according to Waller, but he expects the savings in reduced use of the emergency rooms will more than cover that.

The initial list of chronic ER patients is from the Butterworth and Blodgett ERs, but Waller said he has been in touch with Saint Mary’s Health Care and its list of chronic ER users shows “significant overlap.”

Waller said he is confident Saint Mary’s eventually will refer its chronic ER users to the Center for Integrative Medicine.

“This is meant to be a county-wide clinic, meant to take people from all of these emergency departments” in Kent County, he said.

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