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Hooked on heroin, she sat 2 days in an ER. Hospitals say you pay for this stay, too. – Charlotte Observer

A 25-year-old Gaston County woman who is addicted to heroin waited two days in a hospitals emergency department, in a psychiatric observation room with no bed.

She needed help for her drug addiction, her family says, but local treatment centers were full.

They dont have any place to put them. Theyre so packed, says the womans grandmother.

Instead, the woman was taken to an emergency room by police last month, under a judges order to involuntarily commit her. The womans family says she had threatened to kill herself and theyve been concerned about her health and behavior after learning shes been using heroin for several years.

The ER, according to the family, was the only option.

A growing opioid and heroin epidemic has escalated a problem that health care professionals have been raising concerns about for years: North Carolina has inadequate services for people with mental and behavioral health diseases.

Doctors in North Carolina confirm theres an increasing demand for help and patients are turning to emergency rooms an expensive and ineffective place for treatment.

Often, patients wait days a process called boarding. Hospitals say it takes a toll on their budgets and leaves fewer beds available for other people who need the emergency room.

Most ERs cant provide full substance abuse or psychiatric health treatment. Instead, they can assess patients and offer some medical care then work to transfer patients to specialized treatment centers.

But, when the treatment centers are full, hospitals end up keeping patients inside emergency room departments.

Recently, the North Carolina Hospital Association reported 30 to 80 percent of emergency beds are used for boarding. The result is higher costs for all patients and delays for patients who are in a mental or behavioral health crisis.

For privacy reasons, the Observer is not publishing the name of the Gaston County patient or her grandmother.

Her family says they grew concerned in the past year about changes in the womans behavior. Then, they learned she had started using heroin while she was in college in western North Carolina a few years ago. After graduating from college, she got a job but she stayed hooked on heroin, her grandmother said.

Heroin is an opioid, a class of drugs that now kills more people in North Carolina each year than car wrecks.

This familys experience of a long stay inside an ER and difficulty finding a treatment bed is a common one in North Carolina.

After calling state and local lawmakers to complain about bed shortage, the 70-year-old grandmother called the Observer in late June as her granddaughter waited inside CaroMont Hospitals emergency psychiatric unit in Gastonia.

There, two rooms, separated by gender, house three recliners each for patients. Theres no medical equipment inside and no other furniture, except for an encased television with no wires exposed. Patients may use a wireless phone and are supervised by hospital staff at a nursing station.

This is where the young woman stayed for 48 hours, her grandmother said. Hospitals are required to accept patients in mental health or drug abuse crisis and perform psychiatric evaluation.

CaroMont Hospitals average patient boarding time is four days the same as the states average for adults who are waiting for a transfer to one of North Carolinas three state-run psychiatric hospitals. For a transfer to a taxpayer-supported treatment center, the average statewide wait is 2.5 days.

We will have patients present to our (emergency department) because they have nowhere else to go, said Dr. Tom Davis, chief medical officer for CaroMont.

It is truly a public health crisis and it is really complicated … Our society in general has not funded or put an emphasis on helping to treat and manage mental health problems.

CaroMonts ER sees nearly 90,000 patients a year. When mental and behavioral patients at the ER dont have acute physical medical problems, they can wait in rooms called psychiatric suites.

Davis and other hospital officials said they couldnt talk about the specific case of any patient. When boarding, the hospital prioritizes the patients safety and medical needs, he said. And, if a patient needs follow-up care but not inpatient treatment, hospitals discharge them with a treatment plan.

Patient boarding and gaps in health care services for mental and behavioral health patients are problems nationwide.

But North Carolina, compared to other states, sees nearly twice the rate of psychiatric patients who resort to the ER each year, says Martha Whitecotton, senior vice president for behavioral health services at Carolinas HealthCare System in Charlotte. Carolinas has an emergency room that exclusively serves patients in behavioral health crisis and its often full.

On average, the boarding time at a Carolinas HealthCare emergency room or another facility in the system is about 17 hours.

But we definitely have patients who are there much longer, Whitecotton said, including children and geriatric patients because of fewer beds for those populations.

In Charlotte, both Carolinas HealthCare System and Novant Health told the Observer they board up to 40 patients daily, with some fluctuation, including those who go to the ER in crisis, with mental health and substance abuse issues.

At Novant, the average boarding time varies by location from 10 hours in Huntersville to close to 17 hours at Presbyterian Medical Center in Charlotte.

Many hospitals in the state including Novant, Carolinas and CaroMont are trying to cut down on the boarding wait times by using telemedicine services that include psychiatric consultations by phone and video.

Each time boarding happens, hospitals stand to lose thousands of dollars.

Its draining the system, said Julia Wacker, vice president for community and behavioral health with the North Carolina Hospital Foundation. Its counterproductive in every way.

Nearly 80 percent of mental health and substance abuse patients in North Carolina are covered by Medicaid or dont have insurance, which means tax dollars pay for some of their costs and hospitals absorb the rest.

Hospitals lose money by the hour when they board uninsured and Medicaid or Medicare patients because expenses past the first day of their stay cant be fully reimbursed. Some experts estimate this type of boarding costs about $100 an hour, per patient.

These extended stays in the ER burden hospital budgets, and those costs are being shifted to other patients and payers.

Some doctors and health care administrators say boarding is happening at higher rates because North Carolina doesnt have enough treatment and psychiatric beds. Others say patients are turning to the ER because preventative care for mental health disease and drug addiction is too expensive or inaccessible. Data shows about half of the states counties dont have enough psychiatric doctors.

The stakes are high, with nearly 1,100 opioid deaths annually in North Carolina a death rate higher than murder rates in the state. That figure from 2015 is a 73 percent spike compared to opioid deaths in the state 10 years ago.

Over the same time period, the wait for treatment beds and the number of patients resorting to the emergency room for mental and behavioral health care has gone up fourfold, the hospital association reports.

North Carolinas Department of Health and Human Services is trying to alleviate the boarding problem and related opioid crisis on several fronts. This year, the department introduced new criteria for the groups that manage mental and behavioral health care, and it plans to impose penalties and fees if services arent improved.

Adding beds would reduce some ER boarding but one research project performed in North Carolina suggests the state would need to effectively double the amount of beds it currently has to just ensure patients arent waiting more than 24 hours in a hospital for a transfer a potential solution that would take years to build out and millions of dollars not currently allocated.

Partners Behavioral Health Management is trying to reduce the problem of boarding at ER rooms, said Dr. Michael Forrester, a psychologist and the chief clinical officer. Partners operates in eight N.C. counties, including Gaston, Iredell and Catawba. Its one of seven regional entities that receive state and federal tax dollars to act as a managed care organization for mental and behavioral health needs.

These regional organizations have special care centers for patients who are in mental health or drug addiction crisis, as an alternative to the ER, as well as offering individualized outpatient treatment.

DHHS says many of its solutions for emergency room boarding are routed through Partners and the other regional organizations. One pilot program is running now in 13 N.C. counties, with the aim of diverting patients in behavioral health crisis away from ERs and on to specialty facilities.

A better approach to getting patients the right kind of health care outside of an ER is key, says Billy West, executive director at Daymark Recovery Services, a growing mental health and substance abuse treatment provider, with 32 clinics in North Carolina.

Whether a person is in a mental health crisis, involuntarily committed through court or is personally ready to start drug addiction treatment, West says, doctors and health care providers want to act quickly in that window of time to help a patient. Boarding delays access to long-term health solutions, West said, and may contribute to a dangerous and expensive cycle.

Some statewide statistics suggest this may be happening already.

More than one quarter of Medicaid patients who use an ER for mental and behavioral health issues return to an emergency room the same year with the same problems, North Carolina DHHS statistics show. Of those, nearly 13 percent were return ER visitors within a months time.

In the young womans case in Gastonia, her family worries shell be one of these statistics. After being discharged last month, the woman followed up on outpatient treatment as prescribed by the hospital, says her grandmother, but more waiting may be in the future.

The local outpatient treatment facility shes enrolled in has some wait times for appointments the young woman will need, her grandmother told the Observer Tuesday.

Ill do anything, says the grandmother, who adopted her granddaughter around her first birthday. I want to get her good help now.

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Hooked on heroin, she sat 2 days in an ER. Hospitals say you pay for this stay, too. – Charlotte Observer


‘It’s a big frustration’: Local hospital emergency rooms overwhelmed since passage of Affordable Care Act – The Bakersfield Californian

Emergency room visits are up 29 percent in Kern County since 2009 when the Affordable Care Act was passed, running counter to one of the key takeaways from the law: that they would decrease as consumers take advantage of preventive care.

The problem? Insurance doesnt equal health care access and people still dont know when its appropriate to hit the ER, experts say.

Roughly 51 percent of Kern County ER visits between 2009 and 2016 came from patients enrolled in Medi-Cal, the states insurance plan for low-income individuals, according to data from the Office of Statewide Health Planning and Development analyzed by The Californian.

Medi-Cal was expanded under the ACA, meaning more people have an insurance card. But the number of primary care doctors accepting Medi-Cal hasnt kept up with demand, especially in the Central Valley, and people are still going to ERs for basic care.

People are using the emergency room as their primary care office. People havent really had private doctors, so they dont really know how to use insurance, said Dr. Anthony Iton, senior vice president of The California Endowment, a nonprofit foundation that focuses on health care access.

The result is an added strain on emergency departments across the region, resulting in hospital reorganizations and hiring.

And despite the ACA insuring millions, it still costs hospitals money when Medi-Cal patients walk through the door, said Jan Emerson Shea, vice president of external affairs for the California Hospitals Association.

Now the hospitals are getting a little bit of money, but we still lose on average 40 cents on the dollar for every Medi-Cal patient we treat, Emerson Shea said.

The ACA has eased the burden on taxpayer-funded Kern Medical Center of treating uninsured patients in the ER.

The County of Kern paid $47 million in 2009 to cover the costs of uncompensated care at KMC. Today its financially solvent.

When more Californians began enrolling in Medi-Cal, local hospitals started seeing a surge in emergency room visitors. It has impacted every hospital in Kern County.

Here are the stats for 2009 to 2016:

Valley Childrens Hospital in Madera, the specialty care facility for all southern San Joaquin Valley kids, received 46 percent more emergency room patients, totaling more than 114,000 in 2016 and making it the busiest emergency department in the state (see sidebar).

Not all ER visits, however, have come from people experiencing bona fide emergencies, said Ken Keller, chief operations officer for Bakersfield Memorial Hospital.

We have some come in with a small earache, or a cold, or a flu, or something that doesnt really need to be in an emergency room, Keller said. They have this new benefit they didnt have before, and no education or counseling or outreach to those patients to be able to say, Heres how you access the health care system. What they knew was how to get to an emergency room.

So hospitals have taken on the task of educating patients wandering into emergency departments when they really ought to have gone to doctors offices, Keller said.

Bakersfield Memorial Hospital has hired navigators who can counsel patients on how to seek care outside the emergency room, including finding them primary care doctors who work within their insurance plans, Keller said.

The surge also is forcing hospitals to hire more doctors and staff.

We have more physicians here now than at any point in time than we did seven years ago, Keller said, adding the emergency department has been expanded by about one-third, funded primarily through philanthropy, but also through operating revenue. The hospital recently constructed a pediatric emergency department that has not yet opened and reorganized the way it triages patients.

Jimmy Phillips, administrative director of marketing and communications at San Joaquin Community Hospital, called the surge of patients entering emergency rooms who could have been treated by primary care doctors a big frustration.

Recently, the emergency department has been flooded with patients coming in for things like prescription refills, knee or back pain, cuts and scrapes, fevers and even the common cold, Phillips said.

Those patients, who could have been better served at urgent care facilities, make up roughly 70 percent of SJCHs emergency department admittances, Phillips said, adding that because emergency rooms take patients based on severity of condition, they often face longer wait times for the same quality of care.

Scott Thygerson, the chief strategy officer at Kern Medical Center, said the increase in emergency room admittances has less to do with the Affordable Care Act and more to do with the business of health care and local expansion of emergency departments.

San Joaquin, Mercy Southwest, Mercy Downtown and Bakersfield Memorial have all added beds or expanded their departments since 2009, he said.

When you add expansion, youve got to fill expansion, Thygerson said, pointing to heavy advertising campaigns local hospitals have waged in recent years for their emergency departments. Those emergency departments make up roughly half the admits in the hospital, he said.

Its a big front door, and its the only time a patient truly has a choice where they go for care, Thygerson said, adding that theres no simple answer explaining why emergency department admittances have increased, but that the ACA is just one small part.

State reimbursements to doctors for taking Medi-Cal patients are simply too low for them to justify accepting those patients, leading to the surge in ER visits, said Lanhee Chen, a Republican health care strategist and research fellow at Stanford Universitys Hoover Institution.

Doctors wont accept Medi-Cal patients because reimbursements keep getting crushed, Chen said.

Reimbursements for primary care doctors vary depending on the procedure, but California ranks 48th for their rates nationwide.

Legislators have been working to find solutions. Locally, U.S. Reps. David Valadao, R-Hanford, and Jeff Denham, R-Turlock, have proposed HR 2779, a bill that would field-test the best Medi-Cal reimbursement strategies while incentivizing physicians to work in areas where there are high numbers of Medi-Cal enrollees, like the Central Valley.

Kern County, which has a shortage of providers, high poverty and high infant mortality, is considered to be a medically underserved area by the U.S. Department of Health and Human Services. There arent enough doctors to meet the need.

Here in the valley, we know all too well that possession of an insurance card does not equate to health care services and medical treatment, Valadao said in a statement. By correcting Californias reimbursement method, we can encourage medical professionals to not only set up their practices in the valley, but to provide medical services to all patients, including those who rely on the Medicaid program.

At the state level, Gov. Jerry Brown struck a budget deal with lawmakers last week that set aside $546 million in tobacco tax money for Medi-Cal provider reimbursements roughly half the $1 billion annual estimate of what the measure would generate when voters approved Proposition 56 in 2016.

But even that isnt enough to fix the problem, Chen said.

With the volume of people were talking about with Medicaid, Im not sure that amount of money will be sufficient to deal with the issue. Its not about throwing money at the problem, Chen said. It gets back to the systemic challenges of Medicaid.

Youve got a program that does not have a benefit structure that incentivizes beneficiaries to stay healthy. Its about treating them once theyre sick, and thats not an effective way to manage a population.

A more permanent solution, said The California Endowments Dr. Iton, would be to look at a statewide policy and plan to increase the number of primary care doctors in rural areas of the state where demand is growing.

He suggested the state pay a geographical premium for Medi-Cal reimbursements where theres a dearth of doctors, and create scholarships and incentives for family practice specialties in rural areas while building residency programs that could lure young doctors to practice in the areas where they were educated.

They need sufficient resources infused to match the scale of the problem, Iton said. Right now, were not anywhere close to matching the scale of the problem.

Harold Pierce can be reached at 661-395-7404. Follow him on Twitter: @RoldyPierce.

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‘It’s a big frustration’: Local hospital emergency rooms overwhelmed since passage of Affordable Care Act – The Bakersfield Californian


What you should know about freestanding emergency centers – TribTalk

When struck with an illness or injury, sometimes its hard to know where to go for treatment. With so many options for care, including emergency centers and urgent care centers, knowing where to turn during a medical emergency can save precious time, provide the best possible outcome and can ensure you receive the best value for the care provided.

When you need a facility that is open 24/7 and offers a higher level of care to deal with an emergency situation, a hospital-owned and operated emergency center is your best option for a number of reasons. These emergency centers may be freestanding or located within hospitals. While freestanding emergency centers (FECs) are structurally separate from hospitals, they are capable of delivering emergency services 24 hours a day, seven days a week.

According to the Texas Hospital Association, Texas has more FECs than any other state. Out of the 345 FECs in Texas, however, less than 40 percent are hospital owned and operated. That means that more than 60 percent of the FECs in our state are not affiliated with nor owned by hospitals, which often means they are not owned by healthcare operators. These independently owned FECs are not required to comply with the regulatory and accreditation requirements that hospitals are subject to, and therefore, they do not provide outcomes data to state and federal agencies.

At St. Davids HealthCare, each St. Davids Emergency Center serves as an extension of a St. Davids HealthCare hospital, and these centers are staffed by board-certified emergency room physicians and nurses with experience treating emergent injuries and serious medical conditions. St. Davids Emergency Centers are subject to the same licensing and operational requirements as our hospitals because each is licensed as part of a hospital.

With hospital-affiliated freestanding emergency departments like the St. Davids Emergency Centers, there is a seamless continuum of care should a patient need to be transferred to an inpatient hospital setting. As hospital-affiliated freestanding emergency departments, St. Davids Emergency Centers also meet the criteria established by Austin-Travis County EMS to receive patients being transported by ambulance. Each center has a dedicated ambulance bay for the intake of EMS patients.

Within St. David’s HealthCare, our freestanding emergency departments treat the same clinical conditions as emergency departments within hospital facilities. As such, billing is the same for the traditional hospital emergency department as for the hospital-affiliated freestanding emergency department. St. Davids Emergency Centers are considered in-network with most major insurance companies, and they participate in government programs such as Medicaid, Medicare and TRICARE, whereas many independent FECs that are not affiliated with a hospital do not.

As the number of independent, non-hospital-affiliated FECs grows in Texas, its important that patients understand the differences between the various emergency care options. Moreover, it is prudent that patients seek out the appropriate care setting for the acuity, or seriousness, of their needs. In addition to emergency rooms at six St. Davids HealthCare hospitals in Central Texas, you can also find St. Davids Emergency Centers across the region.

For less acute illnesses and injuries that dont require emergency treatment, urgent care centers which are lower-cost alternatives to emergency departments are the better option for patients. Urgent care centers treat non-emergent medical problems that can develop unexpectedly and require immediate attention, filling the gap between primary care physicians and hospital emergency rooms. As healthcare continues to evolve, consumers are looking for quality, convenient and cost-effective options for care and treatment. Urgent care clinics have become a broadly used form of care for many and are seen as convenient and quick solutions for a host of medical needs.

For more information, see the Texas Hospital Associations article Setting the Record Straight on Freestanding Emergency Centers in Texas.

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What you should know about freestanding emergency centers – TribTalk


Rep. Haddad: ER wait times show it’s time for mental health solutions – Fall River Herald News

Stephanie Murray State House News Service

BOSTON For a mentally ill person in a crisis, it can be difficult to travel to an emergency room and seek help. But if they are able to make that trip, those patients are often left waiting for care for 16 to 24 hours at Massachusetts hospitals. That’s over three times longer than patients who wait about four hours to be seen for non-mental health care.

And without new laws, Speaker Pro Tempore Patricia Haddad says “nothing’s going to change.”

Looking to address emergency room wait times for patients who need mental health care, Haddad spoke before the Joint Committee on Mental Health, Substance Abuse and Recovery on Monday in support of two bills she filed to create a pilot program for mental health patients at Taunton State Hospital and intensive stabilization and treatment units within the state’s Department of Mental Health.

“Let’s get people into a setting where they’re actually getting help,” Haddad said. “And they’re not waiting for help, they’re actually getting it.”

Patients who visit Massachusetts emergency rooms seeking mental health care wait for an inpatient bed significantly longer than patients who require care not related to mental health, according to a study published in the Annals of Emergency Medicine, an international medical journal. Wait times climb higher for the uninsured and Medicaid enrollees, who are more likely to spend over 24 hours in the emergency department.

The study said “mental health boarding” consumes scarce emergency room resources and worsens crowding “so that other patients with undifferentiated, potentially life-threatening conditions wait longer to be seen and treated.”

“There are going to be backups, there are going to continue to be hospitals and private places that just can’t handle these people. So what happens very often is they stay in the emergency room until they calm down and then many of them, their families just take them out,” Haddad said. “They say okay, well the crisis has passed and we have nowhere to put this person and you’re saying there’s nowhere to go so after 24, 48, sometimes even 72 hours, they take them home.”

The two Haddad-sponsored bills, H 1064 and H 1065, were also filed by Sen. President Pro Tempore Marc Pacheco.

The first bill would create a pilot program at Taunton State Hospital to “accept medically stable, high acuity behavioral health and dual diagnosis patients from emergency departments in the Southeast region.” If a patient in need of mental health care cannot be placed in an appropriate setting within four hours of admission, the bill would require they be transferred to the pilot program.

Dual diagnosis, according to the bill, means a patient is mentally ill and has a substance abuse problem. The pilot department would be staffed by registered nurses and psychiatrists, among others.

Taunton State Hospital would be allowed to accept patients to the pilot program who are classified under Section 12 of Chapter 123 of the General Laws, meaning they are at serious risk of harming themselves or others due to mental illness.

“If we did something at Taunton State Hospital I think it would create a few new beds. And to me, that’s the answer,” Haddad said.

The second bill, H 1065, calls for the state Department of Mental Health to create at least two intensive stabilization and treatment units — one for men and one for women. The units would serve patients who “exhibit persistently aggressive of self-destructive behavior” or violent behavior that requires specialized care.

The units would provide services like evaluation, stabilization and psychiatric treatment. At the end of a patient’s stay, the staff would be responsible for developing a plan for the “safe and timely transfer” of the patient out of the intensive stabilization and treatment unit. Other services would include violence assessments, interpersonal conflict resolution strategies, critical incident debriefings and transfer evaluations.

According to the bill, “appropriate staffing” would include registered nurses, clinical social workers, mental health workers, psychiatrists, clinical psychologists and rehabilitation specialists — all who have undergone specialized training to work with the patient population the bill aims to help.

“For those who are very difficult to manage, they’re violent or whatever,” Haddad said. “We need to staff that with people who understand how difficult that job is and are willing to do it.”

A similar program at Taunton State Hospital that treated more than a dozen men with severe mental illness was shut down in 2003 in an effort to save money.

Haddad said long wait times will remain “the status quo” for patients who need mental health care if legislation is not passed.

“I’ve filed it before, I’ve talked about it before,” Haddad said.

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Rep. Haddad: ER wait times show it’s time for mental health solutions – Fall River Herald News


Wisconsin proposal would help keep chronically ill out of emergency rooms – Milwaukee Journal Sentinel

The emergency room entrance at Columbia St. Mary’s Hospital’s emergency department at 2301 N. Lake Drive in Milwaukee.(Photo: Mike De Sisti / Milwaukee Journal Sentinel)Buy Photo

MADISON – Last year in Wisconsin, thousands of people visited an emergency room more than seven times eacha stream of bad outcomes for taxpayers, the health care industry and the patients themselves.

To respond, lawmakers voted last week to givehospitals a powerful financial incentive to reduce emergency room costs within the state’s Medicaid health programs for the needy.

The pilot proposal: Work with diabetics and patients with asthmaandheart disease to control the health conditions that are landing them in the emergency room. If successful, the proposal could mitigate millions of dollars in unnecessary costs for taxpayers and give patients better lives to boot.

“It’s really creative,” said Eric Borgerding, the CEO of the Wisconsin Hospital Association and a supporter of the proposal. “I’m confident it will result in a reduction of emergency department utilization.”

The approach: Payhealth care providers to prevent bad outcomes and emergency room visits for patients rather than paying them even more to provide emergency room care after a patient has had a bout with asthma, or worse yet, a heart attack.

The caveat: Gov. Scott Walker’s administration wasn’t closely involved in the proposal and is still reviewing it, with one top official asking whether the state needs a completely new initiative to accomplish what its existing programs couldbe doing already.

Pointing to numbers from the state hospital association, Borgerding and Rep. Joe Sanfelippo (R-New Berlin) said that last year 10,000 Medicaid recipients in Wisconsin used an emergency room more than seven times at a total cost of $52 million.

Sanfelippo worked on the Medicaidpilot after seeing the success that Aurora Health Care and St. Joseph Hospitals were having with a similar initiative.

“I thought, ‘Hey, maybe this is a trend and something we can build on,’ ” Sanfelippo said of the hospitals’ efforts.

By working with a core group of frequent ER visitors, the hospitals worked to ensure that patients regularly saw a primary care doctor, dealing with challenges ranging from child care and transportation to mental illness. Aurora cut per patient costs by an average of $55,000 within the target groupat its St. Luke’s hospital and nearly $34,000 a patient at its Sinai location. St. Luke’s saw a startling 68% decrease in ER visits and an 80% cut in ER costs among the targeted patients.

“We think there’s a lot of room for expanding this,” said Mark Huber, Aurora’s senior vice president for social responsibility.

Anne Johnson, an emergency room physician for Aurora, gives the example of a patient in her 60s with emphysema and anxiety issues who used to showup at the ER five times a month.

A team at Aurora that included a social worker looked into the woman’s case, working to ensure she got the medicine needed to manage her condition and contacting the woman’s niece about her aunt’s challenges.

“Her family member had no idea,” Johnson said.

Today, the woman is coping with her condition much better and only needs the emergency room every six months, Johnson said.

Sanfelippo’s proposal, which was approved by the Joint Finance Committee Thursday, would set aside $2.3 million over the next two years to encourage hospitals and health systems to take similar steps. The provision in the state budget still needs to be approved by both houses of the Legislature and Walker.

Under the program, hospitals and health systems would get up to $1,000 a year for each frequent emergency room patient enrolled and try to lower his or her ER use and costs. If the health systems prevented ER visits and saved money for taxpayers, the state Department of Health Services would pay half of the savings to the health care provider.

Sen. Jon Erpenbach (D-Middleton) didn’t rule out Sanfelippo’s proposal but noted there were other approaches to prevent emergency room use, including expanding the state’s Medicaid program to more people.

“There’s a lot of ways to work on over-utilization of the ER,” he said.

State Medicaid director Michael Heifetz was also cautious.

Heifetz acknowledged the need to actively manage Medicaid patients’ cases. But he also pointed out that the great majority of patients in Medicaid are already in HMOs, which should be doing at least some of this work already.

The proposal also lays out in some detail how to add more case management into the state’s system, reducing the flexibility for state officials, he said.

“It’s very prescriptive and needs further review,” Heifetz said of the provisions.

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Wisconsin proposal would help keep chronically ill out of emergency rooms – Milwaukee Journal Sentinel


Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER – WBUR

wbur (Open Grid Scheduler / Grid Engine/Flickr)

If you’re wondering why health care costs so much in the U.S., here’s one little piece of the answer: emergency room visits.

Forty-two percent of emergency room visits in Massachusetts in 2015 were for problems that could have been treated by a primary care doctor, according to the state’s Health Policy Commission. This state agency, which is charged with driving down costs, says a 5 percent cut in avoidable emergency room trips would save $12 million a year; 10 percent fewer such visits would save $24 million.

That extra spending is passed on to all of us in the form of higher health insurance premiums. Andgoing to an emergency room for non-urgent care is often not the best move.

“If its not a true emergency, youre going to wait for hours in the emergency room, its not the best practice for coordinated care, and you run the risk of having a lot of tests that might not have been necessary if you saw your regular provider,” saidSarah Sadownik, deputy director of the research and cost trends team at the Health Policy Commission.

The commission is breaking down some of the ways we in Massachusetts could save money without doing ourselves any harm. We’ll be posting many of these tips as they are released.

What’s your guess about the most common reason your neighbors go to an emergency department (ED)? Here’s the answer, by zip code:

Statewide, the top five reasons are: sinus problems (sinusitis), stomach pain (that’s my work zip code), rashes and skin conditions, acid reflux and bronchitis.

I go to the ED on weekends or after 5 p.m. when the office of my wonderful doctor is closed. But it looks like most people go during office hours.

Sometimes we go to the emergency room because we can’t tell if our symptoms signal a common problem or something more serious.

We used to assume that most of the people who visit an emergency room were uninsured. But that doesn’t seem to have been the case before the state expanded health coverage and is likely even less true now. Here’s the most recentcomparison we could find.

I’m surprised cost is not a factor for more people. An emergency room visit is more expensive than going to see your doctoror visiting urgent care facilities, which are often open on evenings and weekends. So what’s missing from this analysis? What are your reasons for going to the Emergency Department?

If you want more juicy details about avoidable ED visits, try this. And if you’re up for a deep dive into the reasons Massachusetts has some of the highest health care costs in the country, and maybe the world here’s the HPC’s most recent cost trends report.

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Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER – WBUR


Lawmakers hit freestanding emergency rooms with mediation and disclosure requirements –

Sky Canaves, Houston Chronicle

An emergency room entrance is seen in a file photo.

An emergency room entrance is seen in a file photo.

Lawmakers hit freestanding emergency rooms with mediation and disclosure requirements

AUSTIN — The House voted 129-11 on Wednesday in favor of the Senate’s version of a bill that will force freestanding emergency rooms and other out-of-network providers into mediation with customers who dispute surprise bills under a state program launched in 2009.

Senate Bill 507 also requires that bills sent to patients include a prominent explanation of the mediation process. The legislation was passed in the Senate in late March and approved by the House Insurance Committee on Tuesday.

Surprise medical bills, also known as balance bills, typically arise when patients seek care at an in-network facility, such as a hospital, but are treated by an out-of-network provider. A recent study by the Center for Public Policy Priorities found that more than 300 hospital emergency rooms in Texas do not have a single ER doctor covered by the state’s three largest insurance plans.

Beyond the standard hospital emergency rooms, over the past five years Texas has seen a boom in freestanding emergency care centers, with more than 200 currently in operation. These account for nearly 70 percent of out-of-network emergency claims, according to Texans for Affordable Healthcare, a coalition of insurance companies, hospitals, and underwriters that supports legislation to rein in costs.

Recent research has found that Texans are more likely to receive surprise medical bills than residents of most other states. State residents have a 34 percent chance of receiving an unexpected bill as a result of being admitted to a hospital through the emergency room, compared to 20 percent nationwide, according to a report published in Health Affairs in February.

In 2009, the state adopted a mediation process for surprise bills arising from hospital ER visits, but it appears that few of those eligible have taken advantage of the option. Only 3,800 patients have sought mediation since the program’s introduction, while the Center for Public Policy estimates 250,000 people covered under eligible health plans will receive surprise bills for out-of-network services within a two-year period.

The House also voted on Wednesday for final passage of a bill requiring freestanding emergency rooms to provide notice of whether they participate in any health plan networks, since many do not. House Bill 3276, sponsored by State Rep. Tom Oliverson, R-Cypress, aims to clarity the status of these facilities in order to help patients avoid surprise bills later on.

Another pair of bills that would limit how much freestanding emergency care facilities can charge for services have been left pending in their respective Senate and House committees.

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Lawmakers hit freestanding emergency rooms with mediation and disclosure requirements –