Healthcare Organization Emergency Room over Utilization

1905 Words8 Pages
Emergency room over utilization is one of the leading causes of today’s ever increasing healthcare costs. The majority of the patients seen in emergency rooms across the nation are Medicaid recipients, for non-emergent reasons. The federal government initiated Medicaid Managed Care programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is ‘Yes’ and ‘No’.
Throughout the early 1980’s and 1990’s the Federal Medicaid program was challenged by rapidly rising Medicaid program costs and an increasing number of uninsured population. One of the primary reasons for the overall increase in healthcare costs is the over
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As enrollment increased emergency room over-utilization for non-emergent reasons decreased. The new Medicaid Managed Care population was being educated on the ‘Gate Keeper’ concept; the idea of having a primary care physician. A large primary care pediatric practice launched an Emergency Room diversion pilot program and conducted a study of Medicaid recipients, 18 years and younger . (2) 17,382 children were enrolled in an enhanced access group (intervention group) and 26,066 received services from other local primary care providers (control group). (2) The twelve month study results showed that the average per member per month cost of emergency room utilization of the intervention group was $1.36 less than the controlled group. There was no significant difference in terms of per-visit cost related to emergency room usage. Although the overall cost of healthcare delivery has not increased the enrollment in traditional Medicaid fee-for-service product has increased and surpassed Medicaid managed care enrollment in the past six years. This recent change in the market place is of particular concern. The idea of losing what has been gained such as, guaranteed access to providers, improved care management attributed to primary care provider healthcare delivery and the ability to monitor insurance carrier performance motivated State Medicaid agencies to devise a response on how to handle this current issue. Because managed care has delivered a value to Medicaid
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