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Washington State 7 Best Practices

Washington State 7 Best Practices. Dr. Stephen H. Anderson, MD, FACEP. The State Budget. Presented at WSHA Safe Table – ER is for Emergencies 9/24/12. Problem Statement.

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Washington State 7 Best Practices

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  1. Washington State 7 Best Practices Dr. Stephen H. Anderson, MD, FACEP

  2. The State Budget Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

  3. Problem Statement Washington State elected not to cover more than three visits off of a list of over 700+ conditions including chest pain, shortness of breath, abdominal pain, and so much more

  4. 8% Rationale #1 • Emergency departments are filled with “non-emergent visits” that would be better treated in their PCP office. • What Percentage?

  5. 2% Rationale #2 • Emergency Department costs are exorbitant and burden the healthcare system. • What Percentage of all healthcare dollars are spent in the ED?

  6. $12.28 Rationale #3 • “Emergency Physicians and hospitals have been abusing their privilege for years billing the state for non-emergent care.” • Jeff Thompson, CMO of Medicaid, Seattle Times, 2/2012 • What is the reimbursement for a level 1 billing by Medicaid?

  7. Non-Emergent Conditions Defined • Any condition that can wait for up to 24 hours to be seen by a provider • 8% from 2009 and 2010

  8. “Non-emergent conditions” • Retrospective denials for: • Chest pain • Shortness of breath • Hemorrhage in pregnancy • Sudden loss of vision • Gallstones • Diverticulitis • Cholecystitis • Asthma • COPD • Sprains/Strains/Burns

  9. Legal Issues: EMTALA Rep. Peter Stark, D-CA • Passed in 1986 • Required • Medical Screening • Evaluation to determine if an emergency medical condition exists • Stabilization such that no material deterioration is likely to occur

  10. Prudent Layperson Prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition • placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, • serious impairment to bodily functions, or • serious dysfunction of any bodily organ or part.RCW 48.43.005(12). Included in the ACA in all States in 2014

  11. Parties Involved • HCA • Jeffrey Thompson • Doug Porter • WA ACEP • Team of 3 • WSHA • WSMA

  12. Three Visit Rule Process Legislative HCA Policy CMS Congress Regulatory Media Lay Public Patient Advocates Legal

  13. Victories Along The Way? • November 10, 2011 • Stay granted by Superior Court Judge for Failure to Follow Proper Rulemaking • HCA halted implementation. • Prior denials halted • No lost payment

  14. Center for Medicare and Medicaid Services • Met with Marilyn Tavenner, acting director of CMS • Met with Steve Cha, MD, head of Medicaid • “We agree with you in principle, but we prefer to have you work it out at a state level at this time”…

  15. Return to the TableFocus on Priorities • Improving health outcomes • Preserving Prudent Layperson Protection & access to Emergency Services • Coordinating care for the highest utilizers • Meeting the State’s budget requirements

  16. We Won! • Governor Suspended Three Visit Limit policy April 1st, 2012 • Moved forward with alternative plan in budget proviso on April 10th, 2012 • June 15th, deadline for implementation

  17. The Seven Best Practices Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

  18. A) Electronic Health Information Goal: Exchange patient information among Emergency Departments • Identify frequent users • Get access to treatment plans • Use in providing care • Exceptions for CAHs with financial burden

  19. Emergency Department Information Exchange Registration to the cloud EDIE Alert with Care Plan during MSE Case Management

  20. B) Patient Education Goal: Help patients understand and use appropriate sources of care • Active distribution of educational materials • WSHA/WSMA/ACEP brochure • Discharge instructions

  21. “The Poster” 2.0 Not to supplant or interfere with Medical Screening Exam

  22. Warning What about my Press-Gainey Scores?

  23. C) Patients Requiring Coordination (PRC)“Superutilizers” Goal: Ensure hospitals know when they are treating a PRC patient and treat accordingly • PRC clients = frequent ER users, MOST VULNERABLE. 80% concomitant mental health & drug & alcohol issues • Receive and use client list • Identify patients on arrival • Develop and coordinate case management programs • Use care plans

  24. D&E) PRC Client Care Plans and Follow up Goal: Assist PRC clients with their care plans • Contact the PCP on arrival • Appointment within 72 hours when appropriate • If not needed, notify PCP of visit • Relay barriers to care All clients: 3-4% 1-2%

  25. ED Care Plan Standard • Header Information • Date Plan First Created • Date Plan Last Updated • Security Alert • Pain Contract and Scheduled Prescribing

  26. ED Care Plan Standard • Primary Care Provider and Specialist • Past Medical and Surgical History • Substance Use and Abuse History • Mental Health Conditions

  27. Care Plan StandardOptional (Phase 2) • Optional sections, may be made mandatory later. • Barriers to Care Delivery • Radiation Alert • Overdose Alert • Special Care Recommendation • Details

  28. F) Prescription Monitoring Goal: Ensure coordination of prescription drug prescribing practices • Enroll providers in Prescription Monitoring Program: electronic online database with data on patients prescribed controlled substances • Target enrollment for ER providers : • 75% by June 15, 2012 • 90% by December 31, 2012

  29. Prescription Monitoring Programs • Game Changer • 49 out of 50 states have this, largest network shares across 25 states • In WA, 96% of ED providers registered • “REGISTERED” does not equal “USES” • ACEP against mandated use… but imagine Push not Pull, No Bias, part of the EDIE

  30. G) Use of Feedback Information Goal: Review reports, ensure interventions are working • Designate ER leader and quality manager to receive, review, and act on utilization management reports • Involve executive-level leadership

  31. Decrease in ED Prescriptions per month written to PRC Clients in One Hospital

  32. “Dr. Feel-good” Vs. “Grumpy” Find the Best Practice 6 Vs. 108, Pills per shift ?

  33. All others Bring Data! In God we Trust….

  34. Reduced ED visits by 9.9%

  35. Reduced number of visits by frequent clients by 10.7 %

  36. Reduced visits resulting in a narcotic prescription by 24%

  37. What does that mean for patients? Overdose Deaths in WA State MVA Vs. Overdose Deaths

  38. Reduced low-acuity visits by 14.2%

  39. Savings of $33.65 millionwere achieved.

  40. What Did We Learn As Doctors? ? • Advocacy is a process • Relationships are critical • Teamwork is more effective • Can be difficult • Temptation can be the enemy

  41. My Time As Chapter President Find your Allies Focus on your Priorities Believe in Win-Win

  42. Questions?

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