New state law aims to steer Medicaid patients to primary care, not emergency department

Incentivizes hosptials to develop care coordination services

Aurora St. Luke's Medical Center at South 27th Street and West Oklahoma Avenue in Milwaukee.

Last updated on May 14th, 2019 at 04:03 am

Gov. Scott Walker signed Tuesday a new state law that incentivizes hospitals to develop care coordination services in an effort to redirect frequent utilizers of high-cost emergency department services to primary care settings.

Aurora St. Luke’s Medical Center at South 27th Street and West Oklahoma Avenue in Milwaukee.

The legislation, authored by Rep. Jessie Rodriguez, R-Oak Creek, and Rep. Joe Sanfelippo, R-New Berlin, aims to address a driver of Medicaid costs: patients utilizing emergency departments for primary care.

In 2016, more than 10,000 Medicaid recipients in Wisconsin visited emergency departments seven or more times at an estimated cost of $53.5 million. Often those high utilizers either don’t know how to navigate the health care system or don’t have access to other means of care.

“Not only is it costly, but it’s time-consuming,” Rodriguez said. “The ERs are very backed up. And because a patient might not be able to navigate the health care system, they may end up using the ER for their primary care. It’s costly to the state and the patients end up having health crises because they don’t see a doctor often enough.”

Under the new state law, hospitals and health care systems will be reimbursed for developing intensive care coordination services provided to Medicaid recipients, in an effort to reduce the strain on emergency departments and help patients find a better setting for their care.

Programs will pair high utilizers with care coordinators to establish a primary care provider, work with a managed care organization and develop a support system outside of the hospital. Rodriguez said factors like poverty, housing and employment often affect this type of patient’s ability to access care.

“Unfortunately a lot of these patients end up having health problems and (the providers) find out there are other things that have been happening in their life that are causing them to have these problems, because they are poor or there is a lot of trauma in their life,” she said. “So they try to treat the patient holistically and address other issues they may be having.”

Pilot programs at Aurora Health Care St. Luke’s and Sinai Medical Centers in Milwaukee have shown promise, Rodriguez said. Among 255 participating patients, St. Luke’s and Sinai saw overall emergency room visits decrease by 44 percent six months after implementing the program and by 77 percent after 12 months.

Aurora’s program has social workers team up directly with patients to determine the factors contributing to their utilization rate, and staff work to educate patients on the health care system. Once patients have successfully navigated the health care system for six months with assistance, they transition out of the program.

Nick Turkal, president and CEO of Advocate Aurora Health Care, applauded the law, saying it benefits patients and taxpayers.

“The passage of this important piece of legislation enables Wisconsin’s health providers to better manage the care of patients by connecting them to the resources they need in a more appropriate care setting,” Turkal said. “Based on pilot programs within our system, we know that emergency department care coordination holds significant promise, and we’re pleased that state leaders see the enormous potential as well.”


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