As a former emergency medical technician (EMT), I have witnessed provider-patient misunderstandings, lack of medication compliance, and abuse of the emergency medical system. As an applied medical anthropologist, I have come to realize the importance of looking through a cross-cultural lens when evaluating why people do what they do in regards to health and healing practices. I recently completed an internship at the Texas Department of State Health Services (DSHS) during the fall semester of 2012 working on the Purchased Health Services Unit (PHSU) project, Emergency Room Study for Children with Special Health Care Needs (CSHCN), under the Division of Family and Community Health Services.
The Emergency Room Study for Children with Special Health Care Needs (CSHCN) project was developed by the Quality Assurance/Utilization Review branch of the PSHU and is an ongoing study to evaluate ER expenditures. According to the project description, its purpose is “to ascertain whether there is an overuse of the ER in CSHCN Services Program clients, assess the reasons for ER use, and propose a quality initiative to reduce ER use.” Initial findings of my claims data analysis show a dramatic increase in ER claims among CSHCN Services Program clients between fiscal years 2011 and 2012.
In February 2011, budget decreases in health care spending prompted the PHSU to evaluate ER usage among CSHCN Services Program clients in an effort to redistribute funds and assist more individuals. Properly tracking and assessing expenditures is important for this Program because it is not an entitlement program, such as Medicare and Medicaid, therefore has limited funding available to provide comprehensive services to as many clients as possible. The Program has a waiting list for services and when funding allows, these waitlist clients can be afforded “time limited services ” or can be removed from the waitlist to receive permanent ongoing services, so long as they continue to meet eligibility requirements . Therefore, reducing expenditures in one area, such as ER usage, may allow redistribution to another with the potential of serving more clients in need. As a provider of comprehensive services, the CSHCN Services Program strives to provide coordinated care promoting the right service, at the right time, in the right setting.
Originally called the Chronically Ill and Disabled Children Program (CIDC), the CSHCN (Children With Special Health Care Needs) Services Program was initiated in Texas in 1933 with a goal of helping low income children with special health care needs. Under direction of the PHSU, Title V block grant funds are managed to provide direct health benefits and case management to clients, among other family-centered, culturally competent, community-based services. The Program covers CSHCN under the age of 21 as well as individuals of any age with cystic fibrosis living in Texas. It is important to note that Texas’ CSHCN Services Program definition differs slightly from the general population of CSHCN mentioned previously. In addition to the MCHB definition, the CSHCN Services Program requires a physical (body, bodily tissue, or organ) manifestation of the special health care need.
Reducing expenditures begins with identifying alternative sources of funding for ER claims submitted to the CSHCN Services Program. Although non-citizens are ineligible for regular Medicaid benefits, they are potentially eligible for Emergency Medicaid coverage for ER visits. Considering that approximately 85% of CSHCN Services Program clients are non-citizens, Emergency Medicaid is an alternative source of funding that can be billed for ER claims when clients both meet eligibility requirements and have been diagnosed with an emergency medical condition.
In collaboration, PHSU and Texas Medicaid & Healthcare Partnership (TMHP) initiated a process to identify ER claims. When a patient is admitted from the emergency department, the hospital admissions personnel must request a prior authorization, or permission, in order for hospital admissions to be covered by the Program. Once prior authorizations are received by TMHP, a list of admitted clients is compiled and sent to the PHSU to identify clients who may be eligible for Emergency Medicaid, at which time the client is encouraged to apply for benefits. If the client is approved, the ER claim is submitted to Emergency Medicaid for payment, rather than being paid by the CSHCN Services Program. However, although clients are approved for Emergency Medicaid benefits, not all claims are approved and paid. Again, they must both meet eligibility requirements and have an emergency medical condition as defined by Medicaid.
A detailed query was run from the TMHP claims database to obtain all claims with revenue codes for ER services for CSHCN Services Program clients for fiscal years 2010, 2011, and 2012, individually. Using Excel, first I sorted claims by ‘Client Social Security Number’ which indicated that 95% of clients using the ER did not have a social security number and are non-citizens. The data was then sorted by ‘CSHCN PCN Number’ and duplicates were removed to get the unique number of clients using the ER during each fiscal year.
Once the unique dates of service were obtained, I used the ERDX code list to determine which claims were potentially covered by Emergency Medicaid. For purposes of this paper, the Medicaid ERDX code list served two purposes. First, I used the EDRX code list to identity life or limb threatening emergencies from a clinical standpoint versus a prudent layperson, to distinguish between emergent and non-emergent ER visits in an attempt to ascertain possibly avoidable ER use. Second, I obtained payment totals for each claim identified with an ERDX diagnosis code to identify potential CSHCN Services Program savings had the claim been submitted to Emergency Medicaid. Once the unique number of clients, claims, and emergent versus non-emergent claims were identified for each fiscal year, the data was then sorted and analyzed for trends by DSHS region, client ER usage across multiple fiscal years, potential heavy-users identified by five or more ER visits during one fiscal year, and ER visit reason based on ER diagnoses.
Emergency room use increased among the CSHCN Services Program clients between fiscal year 2010 and fiscal year 2012, with the most dramatic increase occurring in 2012 (see Figure 2). The ER claims query pulled a total of 975 claims for fiscal year 2012, of which 924 were claims from non-citizen Program clients. Because 95% of claims are for non-citizens, this analysis focuses on only this group of claims. Additionally, non-citizens are the only group of clients which other sources of funding may be available, namely Emergency Medicaid.
After distinguishing which claims could have potentially been covered by Emergency Medicaid based on the diagnosis code, the CSHCN Services Program expenditures could have been reduced by $502K. Based on this finding, queries for fiscal year 2011, and subsequently fiscal year 2010, were obtained. When comparing the three years, data indicates a dramatic increase in ER use during fiscal year 2012. Therefore, a more detailed analysis of claims during this time period was conducted in an attempt to identify any particular utilization trends among the ER claims.