Insurance carriers: Too much ER usage by private option recipients

Insurance carriers told legislators Tuesday that beneficiaries don’t always understand how to access the health care system and sometimes overuse the emergency room, and that the system needs to better track changes in recipients’ situations.

The executives were reacting to the October report by The Stephen Group, which made similar observations.

The Stephen Group is the consultant hired by the Health Reform Legislative Task Force, which will present proposed changes to Medicaid and the private option by the end of the year. Through the private option, the state purchases private insurance using Medicaid dollars for Arkansans with incomes of no more than 138% of the federal poverty line.

Dr. Stephen Sorsby, vice president of medical affairs for Qualchoice, said a substantial percentage of its private option emergency room usage is done by a relatively few members. One individual visited the ER 58 times in the last 12 months.

“The bottom line is, if you have a member who says, ‘I have chest pain,’ we’re going to cover his ER visit, even if we believe that that member is primarily in the ER because he needs two hots and a cot, so there’s some real social issues there, and as you mentioned, there’s some real limits in terms of what we can do as a carrier to reach out,” he said.

He said such individuals need to be connected to a social system outside health care. Dr. Greg Bledsoe, the state’s surgeon general, later in the meeting called the problem “the medicalization of social need.”

Sorsby said doctors do not have an incentive to code such care appropriately because then they won’t get paid. “Chest pain with, well, probably muscular-skeletal or probably from social needs isn’t going to get paid by anybody, so how is the doc incentivized to put that down?” he said.

However, Bledsoe said ER doctors typically are paid by the hour and would be more concerned about potentially being liable for failing to diagnose a patient with a heart condition than they are about their fees.

Cal Kellogg, Ph.D., vice president and chief strategy officer for Arkansas Blue Cross/Blue Shield, said the private option population tends to go to the doctor only when sick and tends to use the emergency room when other types of care would be more appropriate.

He said Blue Cross has been working to educate private option recipients on using the health care system appropriately. Now, 63% of its private option population is aligned with a primary care physician, with 30% of those participating in a patient-centered medical home, a model where a family physician coordinates care for an individual. Patients who frequently use emergency rooms have been identified and have consulted with case managers to help them access the system better, though some simply don’t comply. Blue Cross also is working on a pilot program at a medical clinic where a behavioral health specialist is working to try to integrate that type of care into the patient’s medical care. He said the program has seen a “significant shift in how individuals react to the medical care” as a result.

Sorsby said the the Department of Human Services must have the ability to make changes in real time. He said insurance carriers can’t change beneficiaries’ addresses even when they know they are no longer correct because their address must match DHS’s system. Twenty percent of the mail Blue Cross sends to private option beneficiaries is returned, and that’s less than when the program began, he said.

DHS Deputy Director Mark White later said carriers send a monthly list of address changes to the agency.

Arkansas has led the nation in its percentage reduction of uninsured residents. However, Sorsby said that simply providing health insurance for individuals will not immediately reduce health care costs. For example, he said health care costs tend to rise for smokers the year they quit smoking and then fall.

John Ryan, president and CEO of Arkansas Health and Wellness, touted some of his carrier’s incentives for healthy behavior such as rewarding individuals for completing health risk assessments.

“Also having them get their flu shots, have a wellness exam, a fitness incentive for the individual – all of these items are really key to developing a healthy member and a healthy Arkansan,” he said. “So properly incentivizing people is a great strategy versus just paying claims and hoping that things come out well.”