Each year, Minnesota’s hospital emergency rooms see thousands of patients with minor illnesses — from coughs to fevers — who could be better treated at a neighborhood clinic at drastically lower cost.
To stem that tide, state authorities are using a sophisticated computer screening tool that detects when people on public health insurance programs make dozens of unnecessary trips to hospital ERs and medical clinics. While largely unknown outside government circles, the program has quietly become a powerful tool to control waste in the multibillion-dollar Medical Assistance program while improving patient care.
The system, known as the Minnesota Restricted Recipient Program, has flagged patients who visited hospital ERs as much as 150 times in a single year. It also found people who routinely hop from one physician to the next searching for prescription painkillers.
By limiting these “high use” patients to a single primary care provider, along with a hospital and one pharmacy, the program is saving taxpayers at least $7 million a year in unnecessary medical costs, state data show.
“We pay for a lot of health care in this state, and we want to make sure the dollars go toward the care people really need,” said Chuck Johnson, deputy commissioner of the Minnesota Department of Human Services, which oversees the program.
While controversial among patients, the restricted program is gaining acceptance among family doctors, who see it as a way to ensure that people with serious illnesses get more consistent care at a far reduced cost. Hundreds of people who once viewed the emergency room as their primary source of care are now going to neighborhood clinics and receiving regular checkups, state officials said.
The savings are significant. For each patient in the program, the state-federal Medical Assistance program saves $4,500 a year in unnecessary outlays. That includes a more than 50 percent reduction in ER visits and inpatient hospital stays, according to a 2015 report from the DHS Inspector General.
One neighborhood clinic, the Native American Community Clinic (NACC) in south Minneapolis, recently tracked the behavior of 14 patients who were placed in the restricted program for high use of medical services.
Within six months, their emergency room visits plunged 57 percent and more than a third of the patients reduced their inpatient hospital stays. Moreover, patients who hadn’t visited the clinic for years began showing up again, enabling doctors to put them on a consistent plan of treatment, said Dr. Kari Rabie, the clinic’s chief medical officer.
“Some of these patients may have visited our clinic once, but they had been to the ER as many as 15 times since we last saw them,” Rabie said. “Now, they are coming back home to us, where we can take care of them in a more coordinated way.”
In addition, by flagging heavy users of prescription drugs, the program has become a new weapon in the state’s fight against painkiller abuse, which claimed the lives of 216 Minnesotans last year, state officials said.
With Medicaid claims data, the program can identify when patients are “doctor shopping,” or hopping from one physician to the next in search of powerful medications. About 85 percent of the roughly 4,500 people in Minnesota’s restricted program have been flagged for excessive use of prescription drugs.
By connecting these patients to a primary-care physician, the program “has the potential to save lives,” said Johnson. “This can halt the drug-seeking behavior and get people the treatment they need.”
Often, placing a patient on the restricted program can lead to a discussion about pain and how much prescription medication is right, said Dr. Robert Levy, a University of Minnesota assistant professor and physician at the Broadway Family Medicine Clinic in Minneapolis.
“Pain is a difficult and emotional topic, and this is one great way to identify people who need help,” he said.
Karen Ackerman, a care coordinator for the Park Nicollet system, said she recently saw a 16-year-old female patient who received nearly 200 imaging studies, including CT scans, MRIs and X-rays, from various clinics within a single 12-month period. Once she was placed in the restricted program, Park Nicollet discovered that the girl was being used by a parent to get prescription drugs. Physicians have since been able to stop the unnecessary tests, which had exposed the girl to harmful radiation, and get the girl’s parent into a treatment program for substance abuse.
In most cases, however, patients are simply suffering from “fragmented care,” and the restricted program forces them to deal with a regular team of clinicians. Ackerman said she refers about 10 patients a month to the program, and their ER visits consistently decline by 50 to 70 percent within six months.
“There are patients out there at sea, floating from one place to another, and there’s really no one guiding their boat,” said Ackerman. “This brings people back into a smaller, more coordinated circle of care.”
Critics, however, say such programs amount to rationing — and needlessly stigmatize people with complicated illnesses who may need to see multiple specialists.
More than 40 states have similar restricted programs — often called “lock-in” programs — to root out fraud and excessive use of medical care in state-funded health insurance programs. Yet few states actually monitor patients to gauge whether their health is improving once they are limited to a single, primary-care provider.
One recent study, published in Health Affairs, suggests the programs do little to reduce abuse of prescription painkillers. Researchers analyzed the medical records of 1,647 enrollees in North Carolina’s restricted program, and found that 55 percent circumvented Medicaid and bought opioids out of their own pockets.
“These programs are pretty good at saving money,” said Andrew Roberts, assistant professor of pharmacy sciences at Creighton University in Omaha and one of the study’s authors. “But you cannot equate fewer paid Medicaid claims with improved health care outcomes.”
While the restricted program can help people get more focused and consistent care, people who find themselves placed on the lists “often feel a real sense of stigma,” Rabie said. Doctors, she added, sometimes reinforce this stigma by assuming that patients on the program are drug seekers who are merely out to manipulate them for prescriptions.
“I have seen doctors put up a steel wall” when they see a patient is on the restricted program list, Rabie said. “And unfortunately, patients feel judged.
“Ideally,” she added, “as you do this over time, you develop a way to talk to these patients and ask the most relevant question, which is, ‘How can I help you with your pain?’ ”