Read the New Yorker study of the Camden Coalition of Healthcare Providers here.
See requirements for Medicaid health homes in the draft request to amend the state plan here.
Read the Kanawha County Healthcare Reform Initiative's case study of ER visits here.
CHARLESTON, W.Va. -- Here's a glimpse of the problem:
In late 2011, Charleston Area Medical Center decided to find out how often people were using its three emergency rooms. They discovered that:
• One patient had signed into Charleston Memorial's ER 108 times in 180 days, between December 2010 and May 2011. Medicare paid all 108 bills.
• Another person, a Medicaid patient, visited Charleston General's emergency room 50 times in the same six months. Medicaid paid all those bills.
• A third, another Medicaid patient, came to the Women and Children's ER 49 times.
In all, CAMC's 36 most frequent users visited its three ERs 978 times in six months, an average of 27 visits apiece. That's once a week.
The 978 visits cost more than $500,000 in unpaid care, said CAMC Vice President Bob Whitler, who instigated the computer search for the data.
The ER is the health system's most expensive way to treat problems. One visit costs an average of $756, Whitler said.
"We expected that most our frequent fliers would be uninsured people" with little ability to pay, Whitler said.
To his amazement, 32 of 36 had insurance.
Twenty nine -- 80 percent -- were insured by Medicaid.
State Medicaid Commissioner Nancy Atkins was not surprised.
"Half of our Medicaid population has no care management at all, period," she said. "We're trying hard to do something about that."
"No care management" means nobody monitors the care of about 200,000 Medicaid recipients. Many have no regular doctor. If they come to the ER 50 times in six months, nobody follows up to see what the problem is. They're on their own, but Medicaid pays the bills.
"We've got to do things differently," Atkins said. "We've got to move toward prevention."
About 61 percent of CAMC's 978 ER visits were not emergencies, Whitler said. The top user at Women and Children's, for instance, was a young mother who brought her baby to the ER when the baby had a problem of any magnitude.
That mom needed help with parenting, Medicaid medical director Jim Becker said. A good care manager would hook her up with a home visiting program or a nurse on-call line.
"If people have good care management and learn how to take better care of themselves, they don't need to go to the ER much," said Pat White, director of Charleston's free clinic, West Virginia Health Right. Only one of her clinic's 22,000 uninsured patients was among CAMC's top 36.
Some frequent users need intensive care management an ER can't provide, Whitler said. The Medicare patient who came to the ER 108 times, for instance, has a painful pancreas condition.
That patient might have come to get pain pills, Becker said. Drug seekers, legitimate or not, are part of the mix, too, he said.
After the managers of Prestera's drug rehab program heard about CAMC's survey, they assigned a care manager to frequent-flier patients. Their ER usage dropped.
"High-quality care management just makes sense," said Perry Bryant, director of West Virginians for Affordable Health Care. It saves money, slows the growth of diabetes and obesity and reduces ER usage.
Medicaid and Medicare pay less than the care costs., Whitler said. Hospitals shift part of that cost to private-pay patients, "so this affects all patients."
In fiscal 2012, Medicaid paid $165 million in hospital bills statewide.
'We've got to do things differently'
Whitler likes to point to the way Camden, N.J., hospitals, doctors and clinics cooperate on this problem.
All Camden hospitals feed ER data into a central database at the Camden Coalition of Healthcare Providers. The coalition sends a social worker/nurse practitioner team to frequent users' homes. Sometimes they can identify the problems easily: incorrect use of asthma inhaler or undiagnosed migraines, for instance. Sometimes they hook patients up with regular care.
The team saves more than it costs.
The coalition sorted high users by zip code and found that senior citizens from one high-rise apartment building were coming to the ER in droves. A physician's assistant started holding a weekly clinic at their building. ER visits dropped substantially.
CAMC is paying attention, Whitler said. "We're trying some things in our own ERs."
CAMC staff will not visit frequent fliers at home, he said. "Our lawyers saw some problems with that." Phone calls don't work well either. "We connected a few [of the 36] with community health centers," he said, but most conversations "were not productive. Maybe they thought we were calling to collect bills."
"Face-to-face works much better," he said. So now CAMC has set up an alarm system to alert the ER staff when a patient arrives for the sixth time in a year. A social worker will talk with the person while they are in the ER to try to help.
If the patient wants regular care, three health centers with sliding scales have agreed to enroll them on a fast track, he said. "Our social workers are excited about it," Whitler said. "We don't know yet how well it will work, but we're trying.
"The hospital can't do it alone," he said. CAMC hopes to work out referral agreements with drug treatment centers, too, and maybe home health, for elderly people who come often for anxiety and problems a home visitor could solve.
ER staffers are not used to referring patients, Whitler said. Traditionally, ERs treat people and get them out, Medicaid Commissioner Atkins said. "You're not thinking about keeping track of them or referring them to someone who might manage their care, but that's got to change," she said. "It's a paradigm shift."
Jeffrey Brenner, the director of the Camden Coalition of Healthcare Providers, agrees. To deal effectively with systemic problems like high users and rampant diabetes, normally competitive agencies have to cooperate, he said. "Entirely new models of how we deliver care are going to have to be designed."
'We've got to move toward prevention'
West Virginia Medicaid administrators want to slow obesity and diabetes while they lower ER use.
In 2009, they paid three community health centers - Cabin Creek, New River and FamilyCare - to see if they could reduce the ER and hospital usage of 1,200 Medicaid patients by giving them extra face-to-face care in the community.
"We know we can't sustain Medicaid the way it is," Atkins said. "So we're looking for preventative models that improve health outcomes and save money."
It was a pilot project.
The centers cut ER and hospital use in half. "CAMC data verified it," Whitler said.
"We didn't do anything magic," said Amber Crist, program development director at Cabin Creek Health Systems. "We gave the patients good care management and more frequent contact, and - this is important - we taught them ways to improve their own health from day to day."