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Monday, October 11, 2004 - Page updated at 12:00 AM

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Taxpayers footing bill for excessive use of ERs

Seattle Times staff reporter

A 47-year-old Snohomish County woman made 131 trips to the hospital emergency room last year — more than once every three days, on average.

Her chief medical complaints: headaches, backache and migraines.

The cost of this emergency care, paid by taxpayers: more than $21,000. And that doesn't count her prescription-drug bill.

The woman topped the Washington Medicaid program's first list of emergency-room "frequent fliers" — patients who make an inordinate number of ER visits and often walk out with a prescription for narcotic painkillers.

The state compiled the list in an attempt to identify heavy emergency-room users on the federal-state insurance program for the poor and steer them to less costly forms of care, such as a doctor's office or community clinic. The heaviest users would be assigned to certain doctors to monitor their care.

The ER list surprised and alarmed Medicaid officials.

A 57-year-old Thurston County man, the No. 3 ER user on the list, traveled throughout Washington and even to Tillamook, Ore., seeking emergency care last year. He visited 59 hospitals for a total of 126 ER visits.

A 46-year-old Spokane County woman made 119 emergency-room visits and obtained 392 prescriptions during the year. Her drug bill alone topped $18,000.

Equally troubling to Medicaid officials, the most-frequent ER users also are big consumers of expensive narcotic painkillers, such as Oxycontin and Vicodin.

The state counted 198 Medicaid patients who made more than 30 visits each to hospital ERs in fiscal year 2002, most commonly complaining of migraines, backache and abdominal pain. They left with a prescription for painkillers 99 percent of the time, the records show.

That has Medicaid officials suspecting that some people are cruising emergency rooms to hunt for painkillers.

"If you were taking the number of drugs they're taking, you wouldn't be able to function," said Doug Porter, Washington's Medicaid director, who added that visiting emergency rooms is a "full-time job" for some patients.

Ken Stark, director of the Division of Alcohol and Substance Abuse of the Washington State Department of Social & Health Services, said drug users are adept at exploiting busy emergency rooms to finagle prescriptions.

"ER doctors err on the side of whatever they need to do to move on to the next patient," Stark said. "Drug seekers have become incredibly proficient at signs and symptoms of pain."

ER costs growing

Medicaid patients are using hospital emergency rooms more than ever. The state spent an average of $967 on emergency care for each Medicaid enrollee last year, a 12 percent increase over the previous year.

Medicaid pays emergency-room physicians $37.18 for each patient, compared with $35.25 for a doctor's office visit by an adult. But Medicaid also pays an additional $170 on average for use of the emergency room, making such visits much more expensive than seeing a regular physician.

The rise in emergency-room costs comes as Washington's Medicaid program is already facing financial strain. A tighter state budget last year prompted Medicaid to reduce adult dental benefits by 25 percent.

The state also was poised to start charging monthly premiums for low-income children for the first time this year before backing off amid protest by children's advocates.

But reining in emergency-room use won't be easy. Poor and disabled people rely on ERs for a host of reasons: trouble finding a doctor who accepts Medicaid; accidents resulting from mental illness or drug abuse; the ease of free transportation to the ER; and the emergency room's 24/7 hours of operation, a not inconsequential factor for low-wage workers who can ill afford time off to see a doctor.

The state wants to slap restrictions on top ER users by assigning each to a single gatekeeper physician to oversee all of their medical needs. The so-called "patients requiring regulation" program was started in the early 1990s but fell out of widespread use with the growth of managed care.

Medicaid officials are reviving the program to pair the top 200 ER users with doctors willing to act as medical traffic cops. But Medicaid officials have been unable to recruit enough doctors to take on all the high ER users, some of whom aren't easy to handle.

"These patients can be belligerent, and they can be demanding," said Porter, the Medicaid director. "These are very difficult patients."

Mental illness and substance-abuse problems compound the challenges of curbing excessive ER use. According to the state analysis, almost nine out of 10 heavy ER users suffer from either psychiatric conditions or alcohol or drug disorders, and more than half have both.

Porter said he plans to ask the Legislature next year for $50 million to expand substance-abuse treatment programs to help divert traffic from emergency rooms. He says the state expects to wring the $50 million out of Medicaid by clamping down on unneeded ER treatments.

A success story

Tara Jensen is No. 228 on the Medicaid ER users list. Last year, the 30-year-old West Seattle woman sought emergency care at four King County hospitals a total of 27 times.

But a trip to Harborview Medical Center with a twisted ankle and a concussion last month marked only her third trip to the emergency room in the first nine months of this year.

Her care is monitored by Janet Stein, a Harborview nurse practitioner, as part of the restricted-patient program.

Jensen, who suffers numerous health problems, benefits from Stein's intimate knowledge of her medical history. Taxpayers benefit because Jensen gets more appropriate, and thus less costly, care.

Except in obvious emergencies, Jensen, who agreed to share her story with The Seattle Times, must check with Stein before seeking medical care. Jensen can fill her prescriptions only at the Walgreens pharmacy in White Center or at Harborview. That way, Stein can keep track of every medication, test and treatment Jensen receives.

Jensen does take painkillers, but Stein said her patient has legitimate health problems and hasn't gone to the ER simply to get drugs.

A short woman with dark circles under her eyes, Jensen has a weary mien that speaks to a life of tumult: abuse, estrangement from family, divorce, an 18-month stint in drug rehabilitation for cocaine, homelessness and a staggering array of illnesses that include borderline personality disorder, diabetes, asthma and a propensity for developing blood clots.

Jensen has been on Medicaid since she was 18. The state first enrolled her in the restricted-patient program in 1998 after she had used the ER 15 times in three months. But it wasn't until she was placed under Stein's care in 2002 that her urgent runs to the hospital decreased.

The restrictions work, Jensen said, because she trusts Stein with her entire well-being. Stein estimates she has saved Jensen from "dozens" of unnecessary ER visits by allaying her anxiety.

"She knows my pain threshold," Jensen said. "If I have pain and I don't understand it, I page her."

Hospitals more vigilant

Hospitals, too, are becoming more vigilant about intercepting frequent ER users. As the provider of first choice for many uninsured people, emergency rooms rarely are moneymakers, said Cassie Sauer, spokeswoman for the Washington State Hospital Association.

Sandra Overby-Cooper, an emergency-room case manager at Tacoma General Hospital, said most ER patients don't really need urgent medical attention. Her hospital ranks patients based on medical need, with priority given to someone with a life-threatening condition.

But often, Overby-Cooper said, the ER sees patients like the woman who sought emergency care recently after breaking her acrylic nail and exposing her nail bed.

Tacoma General's computer system is programmed to flag patients who have visited the ER more than six times in the past 12 months. Overby-Cooper will then write, call or talk to those patients about the importance of seeking scheduled appointments with physicians familiar with their medical histories.

"These repeated visits to the ER are not in their best interest," Overby-Cooper said. "Something gets overlooked, something gets lost when you're treated by different nurses and doctors each time."

As for Jensen and Stein, their relationship has paid dividends both for Jensen and the state

In 2000, Medicaid paid more than $17,500 for Jensen's 47 trips to the ER.

By 2003, the costs of her 27 ER visits had fallen to $7,539.

Still, Medicaid continues to pay thousands of dollars for Jensen's care. She takes about 20 medications daily, for depression, seizures and pain, among other things.

Stein said the costs, while substantial, are justified.

"She is still a very heavy user ([f medical services]. But I don't feel that she is an inappropriately heavy user," Stein said, adding that working with Jensen has been challenging but also inspiring.

Jensen said she is thriving under Stein's care. She recently shed 35 pounds after her diabetes diagnosis.

She's optimistic about regaining her health and even dreams of getting off disability and landing a job.

"I'm doing real good," Jensen said with a determined nod. "I'm a lot stronger now."

Kyung Song: 206-464-2423 or ksong@seattletimes.com

Copyright © 2004 The Seattle Times Company

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