Finding a Fair Replacement for Virginia’s ER Utilization Program

Our Complex Care Proposal for Virginia

We have been working in both the political and legal worlds to remove a problematic Virginia budget item that is shortchanging, by $40 million, emergency physicians and hospitals that treat Medicaid patients. A similar policy is denying hospitals the full value of services for Medicaid readmissions. The emergency department policy is gutting funding to EDs and physicians by automatically “downcoding” nearly 800 emergency conditions for Medicaid patients — many of them common diagnoses. Reimbursement for these conditions is cut to only $15.45 if the diagnosis determined, after-the-fact, to be on the list of these “avoidable” codes. (You can read about our efforts in 2020, including our court challenges, here.)

Here’s what’s new for the 2021 General Assembly Session: We are working with our partners at Collective Medical to develop a replacement plan that would lower annual medical expenditures for a cohort of 1,500 high-utilizer Medicaid patients. We anticipate a 40% reduction in costs within a year of the program, equating to $36 million in savings.

The Details

Executive Summary

In 2017, the Commonwealth of Virginia contracted with a medical technology company, Collective Medical, to implement its Emergency Department Information Exchange (EDiE) tool across all hospitals in the Commonwealth. With this tool, Virginia has been able to accurately identify individuals with high ED utilization, referred to as “complex care patients.” Over 17,000 such individuals were identified in 2019; 70% of these enrollees had a behavioral health condition. Collective Medical and Community Based Coordination Solutions (CBCS) have collaborated in efforts to successfully address similar issues for over a decade. We offer the following proposal to address the needs of this cohort and reduce associated costs of care for the Commonwealth.

Background

Complex care patients typically struggle with a variety of psychosocial issues. High emergency department utilization often occurs when complex care patients perceive a crisis moment and cannot have their issues adequately addressed with available community services. Collective Medical has successfully worked with CBCS in various communities across the country to improve access for complex care patients and mitigate their crisis events. This has invariably resulted in improve quality and dramatically reduced costs of care within one calendar year.  

Operational Model

Collective Medical and CBCS will work with the Commonwealth to identify 125 complex care Medicaid members for enrollment every month (1,500/year). We encourage a focus on individuals with unmet and/or difficult behavioral health needs. CBCS will employ five teams across Virginia, each responsible for managing 25 enrollees/month. CBCS will coordinate efforts with payers and existing community resources, with a focus on the following five areas of proven success with complex cases:

  1. Direct Patient Engagement

  2. Community Resource Coordination

  3. Customized Care Plan Development

  4. Community Multi-Disciplinary Team Development

  5. Community Controlled Substance Monitoring

We will work to coordinate our efforts with all existing programs and coordination efforts ongoing across Virginia.  

Anticipated Financial ROI

Internal review of Virginia Medicaid data for 2019 shows average costs of $1,100 per ED visit and $13,800 per hospital admission. The same Virginia Medicaid database has identified that, on average, the aforementioned group of 17,000 high utilization patients with 10+ ED visits averaged 15 ED visits, two medical hospital admissions, and approximately $15,000 in separate behavioral health crisis expenditures per patient — or an average expenditure of just over $60,000 per patient.  

Based on this data, Virginia spends $90 million on annual medical expenditures for a cohort of 1,500 high-utilization patients. We anticipate a 40% costs reduction within one year of program implementation for enrolled patients, equating to $36 million in year one savings.

For questions or comments on our proposal, email VACEP Executive Director Sarah Marshall.