Hospitals strain to accommodate climbing ER visits

Oct. 25--Emergency department visits to Washington hospitals have risen more than 16 percent in two years, according to data from the state Department of Health.

That's in line with a national trend since implementation of the Affordable Care Act in late 2013, which brought insurance coverage to millions of people who may have little experience using the health care system in general.

Local hospitals are feeling the crush, adding nursing staff and doubling down on efforts to coordinate with primary care providers and educate patients on when, where and how to best seek medical care.

But those numbers aren't going down anytime soon.

"The increase in the number of adults who are insured, primarily by Medicaid, but also private insurance, has increased ED (emergency department) visits because of lack of primary care access," said Diane Patterson, vice president and chief clinical officer at Yakima Valley Memorial Hospital. "So we are not alone in Yakima."

Memorial had the busiest emergency department in the state for the first two quarters of 2015 with 45,912 visits, according to self-reported data collected by the Health Department. That amounts to about 250 visits every day, on average.

(Close behind were Kadlec Medical Center in Richland, with 42,401 visits in the first half of 2015; and Valley Medical Center in Renton, with 41,622.)

Memorial's emergency department visits in the first half of the year outpaced the first half of 2014 by 17.2 percent, and jumped 28.2 percent from the first half of 2013.

Statewide, hospitals logged 938,651 emergency department visits in the first half of 2015 -- up 16.4 percent from the same period a year earlier, Department of Health data show. (The data exclude hospitals that failed to turn in numbers for each quarter.)

Coverage through the Affordable Care Act (ACA) kicked in at the beginning of 2014, after enrollment opened in October 2013. Prior to the ACA and the Medicaid expansion, 1 in 7 people in Washington were uninsured, said Mary Kay Clunies-Ross, spokeswoman with the Washington State Hospital Association.

"That's a big number," she said. "A million Washington residents who didn't have health insurance, most of whom now do. That's hundreds of thousands more people who are now insured and can go to a doctor, but that doesn't mean that their community has that kind of access."

The increase in emergency department visits runs counter to what many hoped would happen with the onset of the ACA: that newly insured patients would be able to seek care in other settings, rather than relying on the emergency room as their only reliable one-stop shop.

So far, it looks like an upward trend, not a short-term spike, providers say.

"As the number of primary care clinics become saturated ... the difficulty in getting follow-up and securing outpatient visits will continue," said Dr. Keith Butvilas, chief medical officer at PMH Medical Center in Prosser. "I think this trend's going to continue for quite some time."

LEARNING THE SYSTEM

Local hospitals report two different things happening in the recent surge of patients: Some are people who avoided seeking care for years because they were uninsured, and are now presenting in the emergency department with bigger, more complicated health issues. And some are still using the emergency department for non-emergent issues because it's a place they know they can receive care regardless of the time of day.

For that second group of patients, especially, education is crucial, providers say.

The collaborative "ER is for Emergencies" initiative predates the ACA and was proven successful in decreasing Medicaid fee-for-service emergency care costs, as well as non-emergency visits. The initiative advises hospitals on tracking emergency department use to identify and educate "frequent users," and emphasizes creating programs to direct patients to appropriate primary care.

Yakima Valley Farm Workers Clinic recently finished a two-month push to teach 7,000 of its patients about their individual health plans and the benefits available.

"Some of them think, 'Now I have insurance, I can go wherever I want, and the ER is the place to go,'" said chief medical officer Kevin Heidrick. "It's on our systems to educate patients: No, this is how you contact us; this is the number you call; all our clinics have 24-hour services available," to speak to an on-call provider.

Farm Workers has emphasized same-day appointments, getting patients in to see a provider as soon as possible, as well as extended hours in the evenings and on weekends to accommodate patients who can't take time off during the workday. Its dental clinics also have slots reserved for emergency appointments, as dental emergencies often end up in the emergency department, as well.

The organization just completed an initiative with Memorial Hospital where a nurse met with emergency department patients post-visit to ask which clinic the patient typically used; did they call for an appointment before going to the emergency department; and any other barriers that might have kept them from accessing primary care first.

They're still analyzing the results, chief operating officer Glenn Davis said, but he expects many responses along the lines of "I didn't know how serious the situation was; I was concerned."

Anytime Farm Workers has contact with a patient, he said, they talk about options beyond the emergency department.

One of the largest groups using the emergency department is mothers with young children, Heidrick said.

"They perceive: their child was ill, they needed to go there," and weren't aware of other options, he said. "Sometimes all it takes is a telephone call: A provider can give them advice to avoid the emergency department and get them seen the next day," in a clinic setting.

Maybe a cold doesn't require emergent care, "But to that new mom with a 2-month-old, it was an emergency," he said. "Again, it's an educational process on parenting and health care, and that process takes a little bit longer."

INCREASING CAPACITY

Memorial is anticipating 80,000 to 85,000 emergency department visits by year's end, Patterson said.

"That's a pace that we're just not prepared for, facility-wise. ... We definitely have upped staffing," she said. "It's very, very tough."

The oncoming flu season, when ER visits peak in a normal year, could strain the system even more.

It's not just hospital capacity that has to change, says Matt Kollman, chief operating officer for Memorial Physicians. The three Healthy Now "convenient care" clinics now accept all Medicaid, offering patients another option outside the emergency department.

Next year, Kollman said, they've planned for the Healthy Now's and Memorial's primary care clinics to offer up to 18,000 additional primary care visits.

"Part of that is making our care teams more efficient; part of that is adding more bodies," he said.

At the hospital, Patterson said, they've added at least 30 registered nurses to address increased patient volume. In total, including filling vacated positions, she thinks they've hired 75 or 80 registered nurses in the last year.

Farm Workers has added about one new provider at each of its 20 clinics across Washington and Oregon, Davis said. But beyond just adding staff, the organization is increasing capacity through later hours and services, such as on-call providers.

Emergency department visits at PMH in Prosser, a much smaller hospital, were up 15 percent in the first half of 2015 compared to the same period last year.

Typically, PMH only staffs two emergency department nurses for each of its 12-hour shifts. This year, it's added an extra nurse for the peak hours of 3-11 p.m., Dr. Butvilas said. It still has only one physician per shift, but is looking at adding an extra nurse practitioner or physician assistant "if the volume trend continues," he said.

The only after-hours clinic in Prosser is Farm Workers' Valley Vista, which is open until 7 p.m. Monday through Friday. There are no primary care clinics open on weekends, Butvilas said. PMH sees a definite surge of patients during after-work hours.

"Non-urgent, non-emergent things that could be seen in the clinics if they had the ability to stay open," he said.

But PMH works with local clinics and usually gets patients into follow-up appointments within three to five days, he said.

Hospitals engage in "hotspotting" to identify frequent users of the emergency department -- people who may come in five or six times a year -- and reach out to educate those patients. Some frequent users, however, particularly those who are homeless or struggle with mental illness or substance abuse, have non-medical issues that need to be addressed before their emergency department use can go down, Heidrick said.

Data from the state Health Care Authority, which oversees Medicaid, shows that emergency department use among the expanded-Medicaid population shot above almost all other Medicaid groups when the expansion first took effect, but now appears to falling more in line with emergency department use among previously-covered groups.

STILL NOT AFFORDABLE

Even with insurance, patient behavior is still influenced by financial limitations.

"It's difficult to say what's causing an increase in visits to the emergency department. It could be that patients who didn't previously have coverage are now able to access care. Or it could be that patients are delaying the primary care they need because of the increased out-of-pocket costs from rising deductibles," said Amy Diaz, data analyst with KVH Hospital in Ellensburg.

"When chronic or simple medical conditions aren't managed well, patients may need care in the emergency department rather than lower-cost primary care or urgent care settings," she added.

High-deductible plans often have lower monthly premiums, which makes them affordable at face-value, but patients soon discover that they still get hit with big bills before insurance kicks in.

"What I am hearing from hospitals -- they are using charity care dollars not so much for the uninsured, but to help people on high-deductible plans," Clunies-Ross at the Hospital Association said.

Project Access Northwest, a nonprofit based on the west side of the state, works with patients who are eligible for subsidized plans in the insurance exchange but still can't afford their premiums. The premium assistance program contributes as much as $855 a month toward people's expenses, most of it donated by large health systems. The organization also assists people in navigating health care in general.

"We are finding a surprising number of newly insured people. ... They don't know how to use the system; they don't know how to go about finding a doctor and making that first appointment," executive director Sallie Neillie said. "They've got this insurance card; they're either really sick and they go to the ER, or they're not really sick but they don't know where to go, so they go to the ER."

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