Herbkersman pushes for in-home call boxes for Medicaid patients

March 21, 2011 

CHARLESTON — A state legislator wants to reduce the number of Medicaid patients who go to emergency rooms for non-urgent health care by instead offering them a way to get medical advice at home.

But critics said his proposal is untested and could cost the state more than it would save.

Rep. Bill Herbkersman, R-Bluffton, wants the state to pay for a three-year, multimillion-dollar program that would put call boxes in the homes of about 3,000 Medicaid recipients. The “medical console” would give patients access to a 24-hour emergency call center and a 24-hour nursing line, with the intention of keeping patients out of costly emergency rooms.

“It would be a first in the country,” Herbkersman said of the pilot program, which is backed by the director of the state Medicaid agency.

Critics question how physicians can accurately diagnose patients over the telephone. They said a few minutes spent on the phone could lead to life-threatening complications in true emergencies, such as heart attack and stroke.

They also say the untested program seems to invite lawsuits. Call centers likely would over-recommend that callers seek treatment at the hospital to protect themselves from possible litigation. In those cases, the state would be paying twice — for treatment at the hospital and for the at-home call service.

“There is an overwhelming liability incentive for them to collect the fee from Medicaid and then refer them directly to the ER anyway,” according to a statement from the S.C. College of Emergency Physicians. “Their intention is good, but if they’re trying to cut costs, they’re not going to do it through this particular intervention,” said Dr. Sandra Schneider, president of the American College of Emergency Physicians, a national doctors’ association in Washington, D.C. “This could end up costing the people of South Carolina money.”

THE COSTS The cost of the project is unclear.

Herbkersman said he expects the pilot program to be about $3 million a year. Estimates from the Office of the State Budget are significantly higher — total recurring costs of about $182 million. About $54.5 million of that would come from the state — specifically, from the Department of Health and Human Services, an agency operating with a $125 million deficit this year — while the remainder would come from federal funds.

Herbkersman disputes the budget office’s estimate, saying it accounts for all of the state’s Medicaid beneficiaries.

He said he doesn’t want every Medicaid patient to have access to the call boxes — just the so-called emergency room “frequent fliers.”

A report released last month from the S.C. Public Health Institute, a group that analyzes health data, shows “frequent users” account for 10 percent of all costs in hospital emergency departments statewide and are usually insured by Medicare, Medicaid or are self-pay.

The report concludes with solutions attempting to reduce frequent, non-urgent emergency room use, including matching patients with primary-care doctors and promoting programs that offer free drugs for chronic conditions. A Medicaid-covered, 24-hour nursing line was not among the recommendations.

THE SUPPORTERS Rep. W. Brian White, R-Anderson, said the 24-hour emergency-consulting lines could alleviate pressure on emergency rooms from “people who don’t have a family physician.”

“It’s one way to keep those folks out of the ER for coughs and sniffles,” White said of the proposal, which would be tested in five unidentified counties with high rates of emergency room use among Medicaid beneficiaries.

Herbkersman called the proposal “his baby” and said he still is trying to attract widespread support for it.

He said South Carolina would be the first state to test the call boxes as a Medicaid cost-saving measure and estimated the state could save between $10 million and $15 million annually when patients seek treatment over the phone instead of in emergency rooms.

Herbkersman already appears to have strong backing from the state Medicaid agency, which would pay for the program out of its budget.

“The agency has supported this pilot as an innovative way to help physicians better manage individuals with high ER use, and it’s important that physicians are involved,” Department of Health and Human Services director Tony Keck said in a statement.

THE CRITICS

Some physicians say the program would not reduce ER visits.

The S.C. College of Emergency Physicians, a group that represents the state’s emergency doctors, said in a statement the bill “offers no tried-and-tested means of accomplishing” its goal of reducing the number of non-emergency visits to the hospital.

And despite offering a detailed description of the equipment and expertise needed for the program, the bill offers no details on how “these resources will reduce ER visits” or of how savings would be measured, according to the statement.

Finally, the group pointed out the bill says the pilot program would become permanent “regardless of whether it has saved money or wasted money.”

Dr. Sandra Snyder, president of the group’s national branch and a practicing emergency physician in New York, said the call boxes don’t seem worth the costs.

She said fear of lawsuits would cause call center operators to refer patients to the emergency room no matter what.

“They’re not there — how are they going to diagnose an emergency?” Snyder said. “No one is going to take that liability for someone who says they want to go to the ER because they don’t feel right.”

Conversely, she disapproved of anything that could lead to delays during actual emergencies.

THE PROPOSALS Herbkersman, who dismissed the critics as “special interests who are working for someone’s pocketbook,” introduced his proposal as both a House bill and as a proviso, or a one-year budget law.

The House version has been referred to the Committee on Ways and Means. The proviso version was adopted in the House’s proposed budget last week, according to legislative records.

The proposals do not specify how many people would be included in the pilot program, but Herbkersman said he wants the state to test it on about 3,000 residents, selecting people over the age of 65, pregnant women in their third trimester and parents with infants under 6 months. He also wants the state to choose new parents who are poor and under-educated and seniors who live alone.

After being tested in five counties during the three-year testing period, the program would become statewide, Herbkersman said.

The system, according to the proposal, must have “a medical console” which “must have two buttons” that connect to a 24-hour emergency line and a separate 24-hour nursing call center staffed by “registered nurses with a minimum of 10 years’ experience” who are bilingual in English and Spanish.

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