Amid heightened efforts to reduce unnecessary emergency visits, including a recently announced federal pilot to treat low-acuity patients elsewhere, some insurers have already been striving to intervene even before patients resort to 911.
Some patients return to the emergency department again and again because they don’t know where else to seek help, says Eugene Sun, MD, chief medical officer at Blue Cross Blue Shield of New Mexico. “A lot of times it’s a social issue,” Sun says. “They’re hungry. They’re lonely. And sometimes it’s a clinical issue,” he says, “but they don’t know how to get into primary care or they don’t have a primary care doctor assigned.”
Eugene Sun, MD
So starting in 2016, the New Mexico insurer began contracting with Albuquerque paramedics to provide home support for frequent users of the emergency department as well as some recently discharged hospital patients. Once at-risk patients are referred, a paramedic visits the home at least once, checking on everything from home safety to medication difficulties.
The New Mexico program is just one of a number of initiatives that have health care systems, payers, and others teaming up with local emergency responders to reduce unnecessary ED trips. By 2017, there were at least 129 such programs, according to the most recent survey by the National Association of Emergency Medical Technicians. Until recently the lack of payment was a hurdle, but now the money is beginning to flow.
Since early 2018, Anthem has been paying ambulance providers for treatment of minor injuries and illnesses at home or another site, an option that’s now available in all 14 states where Anthem has commercial plans, according to a spokeswoman. In February, CMS announced a pilot program in which it will reimburse ambulance providers for treatment on scene or transport to a nonemergency site, such as an urgent care clinic or a doctor’s office.
Like the New Mexico Blues plan, other payers are channeling payment upstream for services delivered to at-risk patients before they seek out emergency care. In Milwaukee, for example, UnitedHealthcare Community Plan has contracted with the city fire department to make home visits—typically four of them—to vulnerable patients. The first eight patients referred to the program had visited the emergency department a total of 96 times during the prior six months, says Kathleen Schoenauer, director of medical and clinical operations at the plan, which manages care for Medicaid and dual special needs patients in Wisconsin. During the visits, paramedics help patients with their medications and identify any hurdles to primary care access, among other challenges. UnitedHealthcare coordinators accompany the paramedic on the fourth visit to introduce themselves as the patient’s new contact moving forward. “They know that they can call us, if their housing is at risk again, if they are having trouble getting transportation to their doctor, if they want to change doctors,” Schoenauer says.
In the first group of eight patients, costs from ER visits dropped by 42% from the six months prior to their enrollment compared with the six months after. Schoenauer says that as additional patients enrolled in the program who weren’t as-frequent users of the ED, the reduction in ED visit costs leveled off to 27%. Currently the program is enrolling about 60 people annually.
In 2018, Blue Cross Blue Shield of New Mexico’s program reached about 2,000 high utilizers. The reduction in emergency visits has stayed pretty consistent in recent years at 50% to 60% when comparing before and after enrollment, according to Sun. In 2018, the total savings was about $1.3 million due to reduced emergency visits and hospital readmissions.
Now the New Mexico Blues plan is also looking at contracting with additional first responders to provide in-home support, Sun says. The insurer is talking with other hospitals, ambulance services, and health care organizations in Albuquerque about developing a triage system for the city and its surrounding county that would, among other things, send nonemergency patients to urgent care centers instead of hospital EDs. The approach being discussed is similar to what federal officials plan to pilot, says Scott Kasper, executive director of the Albuquerque Ambulance Service. “Lots of patients don’t need to go to the ED,” he says. “We could be taking them to a more appropriate place.”