By Keanan Lane, CCF Research Intern & McCourt School of Public Policy Graduate Student

The recently released findings from the Oregon Health Insurance Experiment have renewed focus on Medicaid coverage and emergency department (ED) utilization.  The results showed an overall increase in ED visits, driven primarily by those classified as “non-emergent,” “primary care treatable,” and “emergency, preventable.”  Despite the national headlines and political chatter it generated, a number of states, including Washington to the north, have been looking to reduce high ED utilization, directing consumers to more appropriate settings for care.

Citing a substantial difference by insurance status – 40% of Medicaid beneficiaries visited an ED compared to 18% of the privately insured – Washington began digging into the issue back in 2012. The state settled on a “no payments for unnecessary visits” policy and to stave off cuts, physicians and hospitals responded with an alternative approach, the adoption of Seven Best Practices:

1. Track emergency department visits to reduce “ED shopping”
2. Implement patient education efforts to re-direct care to the most appropriate setting
3. Institute an extensive case management program to reduce inappropriate emergency department utilization by frequent users
4. Reduce inappropriate ED visits by collaborative use of prompt (72 hour) visits to primary care physicians and improving access to care
5. Implement narcotic guidelines that will discourage narcotic-seeking behavior
6. Track data on patients prescribed controlled substances by widespread participation in the state’s Prescription Monitoring Program (PMP)
7. Track progress of the plan to make sure steps are working

These Seven Best Practices are now being touted as decreasing overall ED visits (9.9% drop), “frequent visitors” (10.7%), visits with a scheduled drug prescription (24%), and low-acuity diagnosis visits (14.2%).  In a new report, the Washington State Health Care Authority (HCA) cites these reductions as saving Medicaid $33.6 million for fiscal year 2013.

How many of these results can be tied to the Seven Best Practices though? HCA mentions the difficulty in isolating the policy from other factors, particularly the transition of Medicaid clients to managed care health plans that occurred within the same period. While the effect of Medicaid managed care on ED use is mixed, its design is often targeted towards increasing the use of primary care over other places of service. But as the report is isolated to ED claims, it’s unclear if there has been a corresponding increase in primary care.

Many of the Seven Best Practices echo the American College of Emergency Physicians’ (ACEP) national recommendations and the ultimate effectiveness of these practices could provide important examples for other states. Prescription monitoring, care coordination, use of information technology, and effectiveness of the public-private approach are all issues that can be reviewed with Washington serving as a case study.