In the debate over Medicaid, a frequently heard claim is that Medicaid recipients overuse emergency rooms for non-emergency care, and that we need to address this problem if we are to contain Medicaid spending.
This past session, the Legislature approved HB 2906, which directs the Oklahoma Health Care Authority, the state’s Medicaid agency, to conduct a study of current and potential ways to reduce trips to the emergency department. Earlier in session, legislation passed the House that would have limited Medicaid coverage to six emergency room visits per year.
However, Health Care Authority data seems to dispel the idea that ER overuse by Medicaid members is as pervasive or as serious a problem as many assume. In State Fiscal Year 2013, there were just over 1 million Oklahomans enrolled in SoonerCare. Of this population, nearly three in four (73.8 percent) made no emergency room visits in a 12-month period. Another 21 percent visited the ER once or twice. Only 11,763 individuals, or 1.1 percent of the Medicaid population, had six or more ER visits. This small population accounted for some 107,000 ER visits, or about one in five of all visits.
Since 2004, the Health Care Authority has operated the High ER utilization project, which identifies and contacts members who have been to the ER more than once in a quarter and provides information about appropriate usage and referrals to care management. The program has a provider education component as well. Since 2007, emergency room usage has declined from an annual average of 0.58 annual visit per member to 0.53 annual visits per member. Although we should be careful about making direct comparisons because of differences in demographic make-up and data sources, ER utilization for Medicaid recipients appears comparable to the overall population. According to the Kaiser Family Foundation, Oklahomans had 488 ER visits per 1,000 people in 2011; OHCA data suggests that Medicaid recipients made 550 visits per 1,000 people in fiscal year 2011.
It’s also not apparent that ER visits are a major expense in the Medicaid program. In fiscal year 2013, total emergency department costs, including facility and professional claims, were $141.0 million, which represents less than 3 percent of total SoonerCare expenditures of $4.97 billion (with ancillary services, the total cost was $178.3 million, or 3.6 percent of total expenditures). The average cost per emergency room visit was $257.31.
The Health Care Authority’s efforts to monitor and prevent inappropriate emergency room usage should certainly be continued. However, the idea that many Medicaid members make unnecessary trips to the ER seems to reflect myths and anecdotes more than reality.