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The Boston Globe

Health & wellness

AUG. 6, 2008

Costly ER still draws many now insured

Thousands of newly insured Massachusetts residents are relying on emergency rooms for routine medical care, an expensive habit that drives up healthcare costs and thwarts a major goal of the state’s first-in-the-nation health insurance law.

The 2006 law requires nearly everyone to have health insurance, coverage the law’s framers hoped would ease overuse of ERs as the newly insured went instead to primary care doctors for non-urgent health needs.

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But a sizable number of patients who obtained state-subsidized insurance have continued to use the ER - at a rate 14 percent higher than Massachusetts residents overall, according to state data compiled at the Globe’s request. Those state-subsidized patients with the lowest incomes, who formerly received free care in emergency rooms and now pay a nominal fee, are using ERs at a rate 27 percent higher than the state average. The data excluded patients whose injuries or ailments were serious enough to warrant admission to a hospital.

Doctors and counselors working the front lines of emergency care say a major reason patients still flock to their doors for routine care is that there are too few primary care physicians in Massachusetts. Some newly insured patients are waiting months for their first visits.

Healthcare leaders say they also need to do more to connect patients with existing physicians and help them break the habit of heading to the local ER.

”Healthcare reform is not a sprint. It’s more of a journey,” said John O’Brien, chief executive and president of UMass Memorial Health Care in Worcester, a city with one of the largest concentrations of newly insured residents.

A number of medical centers have added telephone help lines, counselors, and social workers in their ERs to answer insurance questions, enroll uninsured people, and find them a primary care doctor. UMass Memorial Medical Center has gone further, sending counselors to laundromats, barbershops, farmers markets, and churches. Armed with BlackBerries, portable scanners, and laptops, they sign people up for insurance, as well as food stamps, Social Security disability coverage, and other programs that can provide financial stability and help keep people out of emergency rooms.

Francine Fitz, a 57-year-old Worcester widow who relied on the ER for routine health problems until she was diagnosed with breast cancer last year, is one of the patients the counselors helped enroll for subsidized health insurance. A telemarketer paid $10 an hour, she could not afford her employer’s plan, she said.

Counselor Heather Reddick also helped Fitz find a primary care doctor, her first since childhood. The doctor works at a UMass health center and had just opened his practice to new patients, so Fitz was able to get an appointment the next day.

Now, when she feels sick, Fitz said, she calls her doctor first, instead of heading to the ER.

”I have never seen a doctor who calls me at home to make sure I’m OK,” she said. “He even gives my children his private cellphone number, if they have a question.”

Routine care in ERs is considerably more expensive than at a doctor’s office or community health center. The average charge for treating a non-emergency illness in the ER is $976, according to a 2007 report by the state Division of Health Care Finance and Policy, which estimated that the total bill for non-urgent ER care in Massachusetts exceeded $1 billion in 2005. In comparison, it costs between $84 and $164 to treat a typical ailment such as strep throat in a primary care doctor’s office, according to Blue Cross Blue Shield of Massachusetts, the state’s largest private insurer.

The 2006 law directed the state Department of Public Health to assemble an advisory council that would recommend ways to improve access to healthcare and reduce “inappropriate use of hospital emergency rooms.” The department said the council has begun meeting.

The law also created a subsidized insurance plan, called Commonwealth Care, for working adults who do not qualify for Medicaid coverage and cannot afford private insurance. CommCare customers make up about 40 percent of the state’s 439,000 newly insured.

State data show that CommCare patients used the ER at an annual rate of 557 visits per 1,000 members between Nov. 1, 2006, and Dec. 31, 2007; the statewide average is 488 visits. Use of the ER was highest among the poorest patients, who make up about half of CommCare’s enrollment and pay just $3 per visit. CommCare members with higher incomes have higher co-payments, ranging from $50 to $75 per visit, and their ER usage rates were below the state average.

”It’s going to take some time to educate” the poorest members, said Patrick Holland, chief financial officer for the Commonwealth Health Insurance Connector Authority, the state agency that regulates CommCare. “They probably never had a primary care doctor before.”

Holland said the state expects the managed-care companies that cover CommCare and Medicaid patients to educate and counsel their customers about how and when to call their primary care doctors.

BMC HealthNet Plan, one of the four managed-care companies, has started having nurses call patients who use the ER more than three times a year, said Thomas Traylor, BMC HealthNet’s vice president of federal, state, and local programs. The nurses ask whether patients are taking their prescribed medications, arrange doctors’ appointments, and send educational information.

BMC HealthNet analyzed ER usage among its CommCare and Medicaid patients from July 2007 through March 2008 and found that CommCare members were using the ER at a rate more than three times that of privately insured patients nationwide. Traylor said the company is studying how its intervention program has affected ER usage.

Other managed care companies also are targeting frequent ER users. Network Health calls members who rack up three or more visits in six months. Company executives said the stepped-up approach is helping to lower usage among their Medicaid members but said it is too soon to know its effect on their CommCare patients.

It’s unclear how the new healthcare law has affected overall usage of emergency rooms. The state monitors such visits and releases a report every two years, but the most recent report in 2007 does not account for changes created by the new law.

Several healthcare leaders said they are finding that the state’s youngest adults are among the most reluctant to change their habits. At Massachusetts General Hospital, ER volume has increased lately, especially among people in their 20s and 30s with routine illnesses, said Dr. Alasdair Conn, chief of emergency services.

”Now they have insurance,” he said, “and they are still using the emergency room as they would a primary care physician.”

Kay Lazar can be reached at klazar@globe.com.

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