FINDINGS IN BRIEF

Number of ED visits remained steady prior to COVID-19 pandemic, but severity of visits and costs increased from 2016-2020

The number of ED visits in Virginia remained steady from 2016-2019 before declining in 2020, reflecting the impact of the COVID-19 pandemic. The intensity of services for patients increased during this time, and the average cost of an ED visit increased by 41.5%. An increasing number of visits for mental health and substance abuse issues were a contributing factor to these trends.

Alternatives to an ED visit need to be available and accessible

People go to the ED for many reasons, some include the inability to get an appointment with a physician or limited hours and locations for urgent care centers. A bad experience in an alternative care setting often leads to ED use. Medicaid enrollees often have the most difficult time finding alternative settings. Additionally, primary care provider acceptance of Medicaid enrollees and scheduling practices are often barriers to access.

Some ED visits for patients with chronic conditions and frequent ED users can be prevented

Patients with chronic conditions that go unmanaged in the community present in the ED with an emergency, but those emergencies could have been prevented. Conditions such as diabetes, hypertension, and asthma can be treated and managed, but often result in ED visits if patients don’t get the care they need. Additionally, the vast majority of high utilizers of the ED have mental health or substance abuse diagnoses. Hospital-based and ambulance-based care management programs can be effective at better managing these conditions in the community.

Freestanding EDs should be easily identified to consumers

Freestanding EDs generally serve a similar patient mix to hospital-based EDs, but consumers can confuse them for urgent care centers or hospitals. Improved awareness by consumers can ensure they seek care in the most appropriate setting and avoid surprise medical bills.

POLICY OPTIONS IN BRIEF

There are 6 policy options in the report for Member consideration.

Option: Direct DMAS to collect and report on claim denials from MCOs by provider type (Option 1, page 20)

Option: Direct a study of primary care practice scheduling processes for Medicaid enrollees, including whether Medicaid enrollees are able to get appointments in compliance with MCO contracts (Option 2, page 22)

Option: Establish two grant programs for hospital and ambulance-based care management (Options 3 and 4, pages 25, 27)

Option: Require hospitals to submit ESI codes, reason codes, and social determinant of health Z-codes on claims and require them to be submitted to the APCD (Option 5, page 27)

Option: Require free standing emergency departments to better identify themselves to patients (Option 6, page 30)