Insurers encourage less-costly ER alternatives and Deficit agreement could put Medicare provider payments at risk

Thu Aug 11 10:16:41 PDT 2011

July 29, 2011
Insurers encourage less-costly ER alternatives

Fierce HealthPayer
By Dina Overland

Research shows that up to 20 percent of emergency room (ER) visits could be diverted to less-expensive retail sites, so health insurers like Anthem, UnitedHealth, and Kaiser Permanente are experimenting with various ways to educate their members about valid emergencies and encourage them to take advantage of less-costly alternatives for non-emergency needs, reports the Denver Post.

The incentives for health payers are clear: When an Anthem member is treated at an ER for strep throat, the insurer spends $518. If that same member is treated at an urgent-care clinic, Anthem pays $85. And if the member goes to a retail clinic like Walgreen's, Anthem pays only $35.

To help avoid unnecessary ER-related costs, Anthem buys Internet ads that pop up when a patient searches for "Anthem" and "urgent care." The ads provide a symptom checklist, locator maps for urgent and retail care, and the 24-hour nurse phone line Anthem wants patients to try before seeking medical care. The insurer also makes robo-calls to patients whose recent ER visits were "potentially avoidable" to provide them with alternatives for similar situations. The push is to "empower the member to make choices," Dr. Manish Oza, a medical director for Anthem, told the Post. "Ultimately then it's their decision how they want to spend their money."

Likewise, in Kaiser's attempt to reduce unnecessary ER visits, it found that most ER users have chronic and mental health issues that need closer coordination between primary doctors, nurses, and pharmacies. "We have seen people at the ER 55 times in a year," says Sara Tracy, Kaiser's senior manager of emergency services. The health plan is now calling those patients to a meeting with the primary doctor, a chemical-dependency counselor, and a pharmacist. "We can detox people and improve their quality of life," Tracy said. The initiative has seen patients with an average of 30 ER trips a year drop to below six visits a year.

UnitedHealthcare is also trying to prevent unnecessary ER visits by, for example, requiring a $250 copay for ER visits instead of a $25 copay for an office or urgent-care visit. The insurer also found high ER use by asthma and diabetes sufferers because of incorrect drug usage. UnitedHealth addressed this issue by eliminating some copays for diabetes or asthma visits when patients used regular offices and saw ER claims for those redirected patients drop 70 percent, reports the Post.

To learn more, read the Denver Post article: http://www.denverpost.com/news/ci_18564472

August 1, 2011
Deficit agreement could put Medicare provider payments at risk

AHA News Now

Congressional and White House negotiators yesterday reached an agreement to raise the nation’s debt ceiling and reduce the deficit. The House is slated to vote on the proposal later today and the Senate could follow as early as this evening. Similar in structure to the deal passed by the House late last week, the two-part agreement would raise the debt ceiling by $900 billion – $400 billion immediately and $500 billion in September, following a presidential request – and enact cuts of $917 billion over 10 years.

Medicare and Medicaid would not be impacted by the initial cuts. The second part of the agreement then calls for the formation of a 12-member, bipartisan congressional committee that would be tasked with making recommendations for $1.2-1.5 trillion in additional savings by Nov. 23. The committee could consider reductions to a variety of programs, including Medicare and Medicaid, along with revenue provisions. The committee’s recommendations would then be subject to a simple up-or-down vote before Dec. 23. If the recommendations pass, the president could request an additional increase in the debt ceiling of $1.5 trillion. 

If Congress fails to either act on the committee’s proposal or send a balanced budget amendment to the states before the end of the year, automatic across-the-board spending cuts totaling $1.2 trillion would go into effect. The cuts would apply to both mandatory and discretionary spending programs beginning in 2013. Medicaid would not be subject to the cuts, but Medicare provider payments would face a cut of no more than 2% over nine years (2013-2021). The president would then be authorized to request an additional increase in the debt ceiling of $1.2 trillion. 

“America’s hospitals find it difficult to support a debt ceiling proposal that could negatively affect Medicare for our nation’s seniors,” said AHA President and CEO Rich Umbdenstock. “Hospitals have repeatedly demonstrated a willingness to accept shared sacrifice and do what is best for our country, but our first commitment is to patients, whose access to care could be curtailed by further cuts to Medicare funding for hospital care.”

Anna Parks &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service

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