Medicaid relief was phone call away

A young single mom in Van Buren woke one evening to the sounds of her young daughter crying. Rushing to her bedside mom noticed the child pulling at her ear and felt the heat of a high temp.

Twenty miles away from Cary Medical Center in Caribou, the nearest hospital emergency room, she considered the path ahead of her. The temperature was 12 below zero, the wind was howling and recent mixed precipitation had made the winding Route 1 south a treacherous trip in the daytime, much less at 11 p.m.

Up until March 5, the young woman could go to her phone instead of her car. Placing a call to the ‘Health Connection’ Medical Call Center at Cary Medical Center she would speak personally to an experienced Registered Nurse. Using an approved computerized protocol the nurse would instruct the mom on a variety of things to do to assess the child, reduce the fever and ease the ear pain. The nurse would also arrange an appointment within 24 hours with the baby’s health care provider. The young woman took the advice of the nurse, and confident of the support available coped with the child through the night. The next day she kept her appointment and brought her daughter to her nearby health center for treatment.

Without the availability of the nurse call center the woman would have come to the emergency department. The average payment for an emergency department visit by Medicaid is $200 plus any blood tests or other services. The cost of a visit to the doctor paid by Medicaid is around $30. The program benefits patients and saves money.

The Health Connection Medical Call Center was established in 1997 as a way of deferring patients from unnecessary emergency department Visits and providing them the appropriate level of care. Six out of every ten calls from patients who indicated they had planned to go to the emergency department prior to making the call were redirected to a primary care physician or provided with home care instruction allowing them to manage the problem with self-care.

For more than three years we have been working with the state Medicaid program to partner with us for a demonstration program or pilot project. In 2001 Maine was the second highest user, per capita, of hospital emergency departments in the nation (based on data from the American Hospital Association). There are some 150,000 emergency department visits by Medicaid patients each year in Maine.

The 1999 Maine Medicaid Annual Report on page 11 of the document said this: “Through a study of emergency room use, staff of the Bureau’s Quality Improvement Division found that 85 percent of all emergency room visits were for conditions that are more appropriately treated in the physician office setting.”

The cost of this excessive use of the emergency department by Medicaid patients can reach $30 million annually. A demonstration project where Medicaid patients would call the Nurse Call Center prior to going to the emergency department could save some $10 million each year. A common-sense provision is included in the plan that directs a patient with any “true emergency” to go to their nearest emergency room. Cary’s proposal to the state was to accept a percentage of the savings as payment for the service. The contract would add no new cost to implement. Yet even with the current financial crisis in the Medicaid program, the state has yet to embrace the program.

Our goal was to establish a program where Medicaid patients throughout the state would call the “Health Connection” prior to visiting the emergency department. Without a major contract like the one we had anticipated from the state’s Medicaid program, we have been unable to establish the ‘economies of scale’ that such volume would create in order to grow the service to the next level.

Tragically, time has run out for the Medical Call Center. The erosion of reimbursement from Medicaid and Medicare continues to threaten the financial viability of rural hospitals. To make matters worse, the state continues to expand MaineCare (Medicaid) eligibility while at the same time reducing payments to hospitals. With all of these negative financial implications and a lack of interest by State policy-makers in Augusta, Cary Medical Center had to make a decision prior to the start of the 2004 budget year to shut down the Health Connection Medical Call Center effective March 5. We simply no longer have the resources to wait until the light comes on in Augusta.

Gov. Baldacci challenged those listening to his State of the State address a year ago. His challenge was to have people bring solutions to the state’s budget problems not more problems. He said that he was looking for ideas that would not add new cost to the system but would bring improved efficiency and quality. Somewhere between the State of the State and the State of Mind of some of the administrations policy-makers that message was lost.

Bill Flagg is the director of community relations and development for Cary Medical Center.