By: TAHP | Monday, May 23, 2022

By Jessica Lynch

The use of emergency rooms for primary care services is decreasing, thanks to Medicaid managed care. A recent report by the Texas Health and Human Services Commission (HHSC) shows a 15.5% decrease in the number of potentially preventable emergency room visits in Texas Medicaid and CHIP programs. 

This is great news for both Medicaid members and taxpayers. Utilizing preventative and standard care before conditions become emergencies leads to better health outcomes and to less costly care. 

The report measures potentially preventable emergency department visits, or PPVs, which are emergency treatments for conditions that could have been treated or prevented by a primary care physician or other health care provider in a non-emergency setting. They include treatments for conditions like asthma, stomach aches, and dental pain. HHSC tracks measures like PPVs to ensure accountability for managed care organizations and may suggest areas where primary care services could be improved.

While a variety of factors contribute to PPVs, timely access to primary care is crucial. Monitoring activities by HHSC show managed care organizations continue to perform well in providing access to preventive care, with nearly all in compliance with primary care and dentist access standards. The state continues to experience shortages of specialty providers, especially in rural areas, but this is not unique to managed care.

Managed care plans also undertake additional initiatives to reduce ER utilization. For example,Cook Children’s Healthy Homes Asthma Programstaff work with families of children with asthma to identify and eliminate triggers in the home. Often, cleaning supplies and other products are provided and families receive monthly check-ins and support.

United Healthcare partners with CareBridge, a virtual care option that enrolls STAR+PLUS members who are actively receiving long-term services and support. The member is connected to a CareBridge doctor, nurse practitioner, or behavioral health specialist through a cell-enabled tablet within their home. This tablet enables the team of health care experts to work with the personal attendant, the member’s primary care physician, specialists and the service coordinator to help prevent health problems.

Managed care plans also participate in Performance Improvement Projects (PIPS), which are designed to achieve significant, sustainable improvement in care areas that have a favorable effect on health outcomes and enrollee satisfaction. A report on PIPs involving PPVs for upper respiratory tract infection is forthcoming from HHSC.

This session,SB 1136directed HHSC to develop and implement a plan to reduce ER visits in the Medicaid program. It requires HHSC to coordinate with hospitals and other providers to identify and implement new and existing initiatives based on best practices and models, including alternative payment models and adoption of other cost-effective measures. Alternative payment models are value-based contracting arrangements that encourage innovation that can help sustain the Medicaid program by focusing the entire system on quality and efficiency. HHSC is currently surveying plans and providers for strategies.

In the meantime, HHSC’s report shows that the state’s managed care approach is working. A 15 percent reduction is a great start and likely just the beginning of how managed care can be effective in the long term.