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."

In 18 months, the patients' ER visits were reduced by 60 percent and hospital visits by 49 percent, according to CAMC records.

"We showed it can be done here," Crist said.

The 1,200 patients had tough problems: diabetes, obesity, poverty, heart disease, arthritis, and depression. "Many also deal with things that push health care way down the priority list," Crist said. "The truck breaks down, there's nobody to watch the kids, they don't have the rent, their mother moved in because she can't pay her rent."

How did they get those results? They:

• Worked as a team. Nurses and aides showed patients how to do things at home that kept their blood pressure and sugar down, for instance

• Helped the patient set do-able, concrete goals for exercise, eating and medical maintenance.

• Called periodically between visits for a friendly how's-it-going chat. "Patients take your advice more willingly if they know you care," Crist said.

• Made sure patients used equipment like asthma inhalers correctly.

• Checked medicines to make sure they were up-to-date, not conflicting and being taken correctly. "That was a biggie," Crist said.

• Provided dieticians, depression counselors or drug counselors if needed.

• Got help for practical problems like transportation or child care or a ramp for their home.

• Exchanged medical records by computer with hospitals when necessary.

• Followed up immediately when a patient left a hospital

Most importantly, Medicaid gave each center money to hire a care manager. "That was the key," Crist said. "That's the part we usually can't afford." After the care team and patient agree on a health plan, the manager tracks it.

Medicaid wants to do the same thing statewide for complex patients. "We think there are dramatic savings to be had in this model," Becker said. "Considerable national research says it works." North Carolina saved $1.6 billion in the first five years of a similar program.

"I want to be paying for improved health outcomes, not just for services," Atkins said. "That means paying for prevention. As it is now, people just bill us, and we pay."

Spreading prevention statewide?

Now, under health-care reform, Medicaid can routinely pay West Virginia doctors and clinics to provide care management. "That will make a huge difference," Cabin Creek's Crist said.

"That's been the problem right there," she said. "Insurance would pay us to fix problems, but not to prevent them."

Medicaid has to submit its plan to Washington for approval.

It wants to care-manage obesity, diabetes and drug problems, medical director Becker said. "If we could get a grip on those problems, we could make a huge impact," he said. It should improve health and lower ER use, he said.

Leaders will start small. In early 2013, they plan to ask for permission to start with 7,300 bipolar patients (high drug and ER-users) in five counties. The feds advised them "to get our system running with a small group before we take on a lot of people," Atkins said.

By the end of 2013, they hope to submit a second, much larger request to give obese patients with diabetes and depression care management. That could be as many as 100,000 patients, Becker said.

"We have a real chance to make an impact with obesity and diabetes," he said, "so we want to be ready to hit the ground running. We want to take full advantage of two years at 90 percent."

The feds will pay 90 percent of the cost for two years, then the normal 72 percent.

Until now, half of West Virginia Medicaid's population -- including all mothers and children -- has been monitored by three national health-maintenance companies. "The problem is, they often don't seem to keep up with individual patients," advocate Bryant said. The mother who brought her child to the ER 49 times is assigned to one of the three companies, he noted.

Eight of CAMC's top 36 ER users are assigned to the three companies. "They're supposed to catch inappropriate cost, but they don't notice a patient is going to the ER once or twice a week," Bryant said. "In the care-management model, the providers know what the patients are doing."

To be certified as a health home, West Virginia clinics or doctors' offices will have to go before a Medicaid panel and prove they can supply required services. An online link to draft requirements is at the top of this story at www.wvgazette.com.

In North Carolina, when doctors' offices can't supply all services, they contract for them. "We expect to do that here," Becker said. New jobs will be created in the process.

Medicaid plans health homes for other groups, he said: foster children with specialized problems, people in long-term care, Alzheimer's patients, and mentally ill people with lung disease.

"It's the right direction," CAMC's Whitler said. CAMC's Family Medicine Center is applying for certification as a medical home, he said, "so we'll be ready."

Reach Kate Long at katel...@wvgazette.com or 304-348-1798. 

"The Shape We're In" has been supported by a Dennis A. Hunt Fund for Health Journalism fellowship, administered by the California Endowment Health Journalism Fellowships at the University of Southern California's Annenberg School for Communication and Journalism.

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Here are three facts:

• Seven out of 10 of West Virginia's health-care dollars are spent on obesity-related diseases, including diabetes and heart disease.

• West Virginia spends about $11 billion a year on health care. That will grow to $22 billion by 2018, as obesity and diabetes spread, unless action is taken.

• Half of all health-care dollars pay for the care of the most expensive 5 percent of patients.

Those facts were supplied by health-care economist Ken Thorpe, who was hired by the Legislature to advise the state on ways to save money while improving health. He recommends that West Virginia do three things:

• Get children active every day.

• Create statewide diabetes-prevention classes.

• Get expensive patients into intensive care management to improve their health and reduce their time in ERs and hospitals.

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Improving health, lowering high ER usage

• CAMC's 36 most-frequent emergency room users came to the ER 978 times in six months -- once a week, on average -- according to a 2011 CAMC computer search. The top user came to the ER 108 times in 180 days.

• Only four of the 36 were uninsured. Twenty-three were Medicaid patients.

• Half of all Medicaid patients (200,000 of them) have no care management, which means nobody checks to find out why they are coming to the ER so often.

• In a Medicaid pilot study, three community health centers cut in half the ER and hospital use of 1,200 patients, while improving their health by giving them intensive care management.

• In 2013, Medicaid plans to spread care management statewide, paying West Virginia medical providers to do what the three centers did. "There are dramatic savings to be had with this model," said state Medicaid medical director Jim Becker.