Prevention/Care Management, 2005
State of Oregon
The State of Oregon is using AHRQ products to assess the necessity of emergency room use by Medicaid patients. The emergency department algorithm, developed by former AHRQ Visiting Scholar John C. Billings, is being used to help identify the causes of potentially avoidable use, and to intervene to improve patient access to care and reduce unnecessary costs.
States are required by Federal law to evaluate the quality of care that Medicaid-participating health plans deliver, explains Charles A. Gallia, Evaluation Research Coordinator in Oregon's Office of Medical Assistance Programs (OMAP). In the past, Oregon accomplished these evaluations by labor-intensive chart reviews, and the results were neither timely nor very useful.
However, now that Medicaid managed care plans have been in operation throughout the state for several years, OMAP has accumulated an extensive data base with information on the use of services. The Billings algorithm offers an automated tool to discriminate among emergency department visits—to see which ones were not urgent, which conditions could have been prevented or treated in a primary care physician's office, and to compare health plans on this basis.
Billings developed the emergency department algorithm with the help of a consensus panel of physicians. These physicians reviewed some 6,000 emergency department records and determined the probability that a given condition would fall into one of several categories: non-emergent, emergent and in need of emergency care, emergent but preventable, and emergent but treatable in a primary care setting.
The algorithm was used in the SafetyNet Monitoring Initiative, sponsored by AHRQ and the Health Resources and Services Administration. The goal of the initiative is to provide policymakers with the data and tools they need to understand the state of the safety net in their communities and states. Gallia believes OMAP's use of it shows that it has a much wider potential application.
In their first analysis of their Medicaid data base, Oregon officials focused attention on actionable findings—situations within the health plans' power to improve. They chose asthma, a chronic condition that represents as many as 40 percent of emergency visits. They found a high proportion of asthma visits fell in the avoidable categories, as well as a disparity between English and non-English speaking populations.
Oregon staff presented their findings to the medical directors of the health plans, and are working with them to find better ways of educating patients about appropriate emergency department use. Because language can be an issue, they are developing Spanish-language videos for use in waiting rooms. OMAP will evaluate the success of these targeted educational interventions, adds Gallia.
Free software for using the algorithm can be found at http://www.ahrq.gov/data/safetynet/.
Impact Case Study Identifier: CP3 05-03
AHRQ-Sponsored Activity: Research
AHRQ Product: Safety Net Monitoring Initiative
Billings J. "Using administrative data to monitor access, identify disparities, and assess performance of the safety net." Chapter 5 in Monitoring the Health Care Safety Net: Book III: Tools for Monitoring the Health Care Safety Net. Agency for Healthcare Research and Quality, Rockville, MD. December 2003.
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