As the Chief Population Health Officer at Ballad Health much of my work is based on the belief that the 25 to 30 percent of US health care spending which is waste should be redirected toward better uses including delivery of more high-value care, expanding health care coverage for low-income individuals, and redirecting dollars further upstream towards prevention and investments in social determinants of health such as secure housing, early childhood interventions such as Nurse Family Partnership, and three and four year old pre-K.

I am therefore sympathetic to the Commonwealth’s efforts to reduce Medicaid spend in order to redirect elsewhere poorly spent dollars.  As a former Medicaid Director in South Carolina and Deputy Secretary of Health in Louisiana, I was often called on to do the same.

The May 20, 2020 Notice of intent to Amend the State Plan - Avoidable ER Claims and Hospital Readmissions, however, seems an especially unproductive means of saving dollars by relying on a heavily bureaucratic, and often arbitrary, process of retrospective review while at the same time doing little to reduce the delivery of low-value care in the ED or incentivize the delivery of high value primary and preventive care in the community.

There is no doubt that avoidable visits to the emergency department are a costly problem.  But in comments following up on its study of this issue, the United Health Group, one of the country’s largest health insurers, stated that “uneven access to timely, consumer friendly and convenient primary care options is a long-standing problem, and there is a need to bolster and expand primary care capacity,” and that people would continue to inappropriately use the ER if there was no better choice.

Large swaths of Virginia are primary care shortage areas. Even more shortages exist for dental health professionals and mental health professionals, which is especially important given a significant percentage of avoidable ED visits are related to substance abuse, dental conditions, and mental illness. As a recipient of a CMS Accountable Health Community grant, which DMAS has sponsored, Ballad Health can attest that we also see significant ED use driven by social issues such as housing insecurity, food insecurity, and lack of transportation. While our ED’s are provided funding through this grant to navigate a small number of these high-risk, high-utilizing individuals, most hospitals within Virginia are not able to do so.

If the intended target of this effort is to identify and prevent perceived upcoding, the department’s notice is not clear.  It does make clear that fees will be reduced for diagnoses identified on the avoidable list if deemed non-emergent.  Upcoding by a provider and delivery of services for a diagnosis which is theoretically “avoidable/amenable to primary care” are two different things.

It would make much more sense to address this problem at the Medicaid Managed Care level, setting financial withholds from the MCOs tied to the reduction of ED visits amenable to primary care or the increase in the use of appropriate preventive care.  The MCOs have many more levers to pull – network adequacy, primary care payment policy, mental health parity, and member education, disease management, and care coordination – than do the state’s emergency rooms on their own.  Better yet, DMAS should require the MCOs to expand value-based payments where shared risk will drive partnerships between payors and providers to better manage vulnerable populations with high ED use.

Respectfully submitted,

Anthony Keck