KHI News Service

Trimming Medicaid emergency room visits would create small savings

Most optimistic projections promise $625,000 a year, auditors say

By Mike Shields | March 16, 2011

Eliminating unneeded emergency-room visits by Kansas Medicaid patients would produce only modest savings for the state treasury, auditors for the Kansas Legislature reported today.

In 2008 and 2009, Kansas paid an average of $2.5 million a year for Medicaid emergency room claims, according to the report presented to the Legislative Post Audit Committee. That was only a fraction of the $2.5 billion spent yearly in Kansas on Medicaid services. Or as lead auditor Joe Lawhon put it, "a drop in the bucket."


ER Use by Medicaid Clients

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The state's share of Medicaid is about $750 million a year, the federal government picks up the rest. Medicaid provides health coverage for about 11 percent of the state's population or about 317,000 people. It is available to only the very poor, and low-income pregnant women, the disabled and frail elderly

Lawhon told committee members that the state already has several measures in place to reduce unnecessary emergency room costs. For example, the state pays a reduced rate to hospitals and other providers for "non-urgent health conditions."

The program also pays for some case management services that reduce the likelihood a person will go to the emergency room unnecessarily. It also pays transportation costs to get patients to a primary-care doctor, which eliminates some wasteful visits to emergency wards.

According to the report more than 118,000 Medicaid clients visited emergency rooms in 2008 and 2009. Slightly less than 5 percent of them accounted for 27 percent of the costs; with 27 individuals each going to emergency more than 100 times in the two year period. About 60 percent of those who went to ER were women and 35 percent were children.

The single most frequent user of emergency rooms in 2008 and 2009 was a man who sought treatment on 211 days. Most of his claims were for alcohol-related problems. Hospitals billed a little more than $247,000 for his care and were reimbursed $800 by Medicaid. The man, who was not identified by name, was also on Medicare, which paid some of the hospital costs.

The single most expensive user of emergency rooms was a woman who went to the emergency room on 125 days during the two-year period. About 35 percent of her claims were related to sickle-cell anemia; another 23 percent were for chest pain. Hospitals billed about $111,000 for her care and were reimbursed almost $16,000.

The most common diagnosed medical condition was chest pain. Other common emergency ailments were fever, headache, shortness of breath and urinary tract infection.

In the two-year period examined by the auditors, 642,000 emergency room claims were paid by Kansas Medicaid; 40 percent of the claims resulted in payment of $10 or less.

Auditors concluded that about two-thirds of the emergency room visits were for conditions that didn't require urgent care. But they also noted that their analysis was "after-the-fact."

"As such, it shouldn't be used to conclude that individuals who sought care through an emergency room, rather than a doctor's office, always did so inappropriately. In some cases, for example chest pain or a head injury, it would be appropriate for an individual to seek emergency room care even if the condition turned out to be minor."

In 1986, Congress passed the Emergency Medical Treatment and Labor Act. That law requires emergency room staff to provide medical screening for all who seek care even if they can't pay.

"The combination of this law and the fact that Medicaid must pay for any service rendered, leaves Kansas and other states in a position where they must come up with funding to cover the cost of provided services," auditors wrote.

The audit report also included several "strategies" Kansas could consider implementing to potentially reduce emergency visits.

Among those were:

  • Staff a 24-7 nurse help line that Medicaid clients could call to help assess whether they really needed emergency care.
  • Pay primary care providers to travel to rural areas or to see patients the same day an appointment was made.
  • Educate the public about preventive medicine.
  • Targeted case management for those who use emergency rooms frequently.