Presented by: Melissa McFerran Lee Anne Gerrity Kelly Hall & Brian Burnett

1. Community Presentation:Emergency Departments and their role/responsibility in caring for the uninsured Presented by: Melissa McFerran Lee Anne Gerrity Kelly Hall & Brian Burnett East Tennessee State University

2. Project Overview: Three objectives Identify three common subsets of uninsured patients. Provide Physicians and Nurses with an increased awareness of the root-causes that force the uninsured to seek medical attention for non-emergent conditions in the Emergency Department. Provide cost effective tactics to treat these patients in the ED and offer solutions and resource education to allow these at-risk patients to seek medical attention in a more responsible manner.

3. Why the Emergency Department? Why the reasons are many, we chose to identify three populations of Tennesseans that have the highest utilization of emergency care services, especially those who present with non-life threatening agencies. The uninsured under the age of 18. The uninsured purged from the TennCare roles. The Psychiatric needs patient unable to afford insurance.

4. Uninsured: Under the age of 18 Some surprising statistics for uninsured children: Nationally, children constitute 8.2% of the uninsured populace. The annual percentage of uninsured children rose from 14.2% in 1999 to 15.4% in 2009 and estimates suggest that the percentages will continue to climb. Source: Centers for Disease Control. (2010). National health interview survey, 1997-2009, family care component. Retrieved from http://www.cdc.gov/nchs/vitalstats.com on July 11,2011.

5. Uninsured: Under the age of 18 National versus State statistical Data 2008-2009 Uninsured children TN-134,200 (14%) US-8,284,500(17%) Uninsured poor children(under 100% FPL) TN-63,500 (14%) US-3,682,700(17%) Uninsured low income children (under 200% FPL) TN-97,600 (12%) US-5,993,70(16%) Reference: The Henry J. Kaiser Family Foundation (2009). Retrieved from http://www.statehealthfacts.org on July 11,2011.

6. Uninsured: Tennessee’s Children About 92,000 children were uninsured in 2006. 31,000 were in families whose income was below 100% of the federal poverty level(FPL). 5,000 were in families whose income was between 100% and 149% of FPL. 11,000 were in families whose incomes were 150-199% FPL. 24,000 were in families with 200-249% FPL, all qualify for Cover Kids.

7. Uninsured: Tennessee’s Children The overall impact is that children without health care resources are going to use Emergency Departments as their primary avenue for Health Care access. Currently, children account for 25% of all ED visits. Studies indicate that uninsured children were more likely to identify the ED as their usual site of care compared to insured children.

8. The TennCare Dilemma What is TennCare? TennCare is the state of Tennessee’s version of the Medicaid program. Established in 1994, it is managed by the state of Tennessee and overseen by the federal government. These two governing bodies share the cost of providing health care for those who qualify.Who is eligible for TennCare and what are the requirements?

9. The TennCare Dilemma: Purging the rolls. Reduction of TennCare roles began in 2005 following several years of funding difficulties. This represented the largest single increase in the number of uninsured Americans in the nation’s history and the deepest cuts ever in funding for a public health program (Bonnyman, 2006).

10. The TennCareDilemma: Purging the rolls. Those affected were the 300,000 uninsured and uninsurable adults who totally lost coverage. An actuarial analysis showed that these were among the sickest and highest-cost TennCare enrollees. A 2002 analysis by the University of Tennessee Center for Health Services Research concluded that these dis-enrollments could be expected to increase mortality by 275 deaths a year (Bonnyman, 2006).

11. The TennCareDilemma: Purging the rolls. Who takes the brunt of the impact? The Patients The Hospital The Physicians The Staff

12. The TennCareDilemma: Purging the rolls. What does the future hold? More cuts are still being considered. Legislators are proposing widespread reductions of nearly $130 million in state money (Carroll, 2011). Tennessee hospitals have proposed a fee that would help temporarily avoid millions in TennCare cuts. This investment would save hospitals money by providing people with appropriate care on the front end so they don’t end up needing costly emergency care.

13. The TennCare Dilemma: Purging the rolls. What are the community effects of these cuts? Emergency departments are experiencing overcrowding , placing patients at risks. Heavy financial losses related to lab work and other diagnostic tools that are expensive and completely uncompensated. Emergency Departments are closing their doors to negate heavy financial losses. Surge of charity care and bad debt increased by roughly 300% over the past three years for Methodist Medical Center.

14. The Psychiatric Crisis in the ED Statewide there is a huge reduction in mental health spending. State facilities are reducing psychiatric patient beds by greater than 80% at times. Mobile crisis resources are stretched thin and more patients that need help are having to “contract for safety.” Patients are true “emergency patients” seen in the ED and are heavily resource dependent and the care is uncompensated.

15. The Psychiatric Crisis in the ED State Facilities are declining admissions to committed patients and are sending them back to the Emergency Departments. Non-State owned psychiatric facilities are seeing few, if any, uninsured patients. Out of 37 psychiatric patient transfers*, every uninsured patient went to a state owned facility. * This figure was from two consecutive months of psychiatric transfers dating February and March, 2011.

16. What can we do as Healthcare professionals to help? Education is Key We must educate the parents that resources are available to provide insurance coverage to their children, with little to no costs to them. We must provide them with brochures and resource sheets to help them find the information necessary. We can contact the ED social worker to assist families in the process.

17. What can we do as Healthcare professionals to help? When appropriate, utilize Medical Screening Exams to reinforce the need for reducing non-emergent visits to the ED. Implement a fast, effective, process for treating low acuity patients that are both cost effective and time saving. Involve Physicians to actively provide Rapid Medical Exams throughout the course of the day, and especially when we become busy.

18. What can we do as Healthcare professionals to help? Philosophy Change Minor acuity/non emergent patients should be treated safely and quickly (RME). Do not let them sit in the lobby waiting for them to get frustrated and leave. Walk every patient to the discharge window to increase cash collections. Accurately document any materials and equipment used to reconcile lost charges and bad debt.

19. What can we do as Healthcare professionals to help? Philosophy Change Operational Metric Compliance must be treated with the same value of importance as Core-Measures for Emergency Departments. Operational metrics must be: Clearly defined Measurable Accountable

20. Conclusion/Summation Emergency Departments are increasingly becoming the sole resource for the uninsured and indigent care populace. This population will continue to climb due the state financial crisis and a broken TennCare system. Emergency Departments must have effective coping strategies to handle the increase in patient volumes and bad debt. Emergency Departments much implement tactics that help quickly treat patients and capture revenue streams where ever possible to ensure their survival.

21. Thank You

22. References: Centers for Disease Control. (2010). National health interview survey, 1997-2009, family care component. Retrieved from http://www.cdc.gov/nchs/vitalstats.com on July 11,2011. Berman, S. (2008). Who are the uninsured children in TN? Retrieved from http://www.plateaupediatrics.com/access/2008/06/health-insurance-coverage-for.html. on June 28, 2011. The Henry J. Kaiser Family Foundation (2009). Retrieved from http://www.statehealthfacts.org on July 11,2011. Luo, X., Liu, G, Frush, K., Hey, L. (2003). Children’s health insurance status and emergency department utilization in the united states. Pediatrics. 112 (2), 314-319. Associated Press. (2011, February 10). Hospitals want fee to prevent TennCare cuts. WATE.com. Retrieved July 8, 2011, from http://www.wate.com/story/14010079/hospitals-want-fee-to-prevent-tenncare-cuts Bonnyman, G. (2006). The TennCare Cuts: Plunging Into The Unknown. Retrieved July 8, 2011, from www.mtsu.edu/~berc/tnbiz/pdfs/healthcare/bonnyman60906.pdf

23. References: cont. Carroll, C. (2011, May 3). Advocacy group warns against TennCare cuts. Times Free Press. Retrieved July 10, 2011, from http://www.timesfreepress.com/news/2011/may/03/advocacy-group-warns-against-tenncare-cuts Farley, K., & Tucker, L. (2006, July 20). Local providers create solutions after TennCare cuts. WATE.com. Retrieved July 8, 2011, from http://www.wate.com/story/5176901/local-providers-create-solutions-after-tenncare-cuts Tennessee Medical Association. (2011). Hospital Fee Renewal Averts Some July 1 TennCare Cuts. Retrieved July 8, 2011, from http://www.tnmed.org/TCcuts_July1/ TN.gov. (2011, January). TennCare 101: Explaining the Basics of Medicaid in Tennessee. Retrieved July 10, 2011, from www.tn.gov Tennessee Department of Mental Health and Developmental Disabilities. (2010). FY 2101 Joint Annual Report. Retrieved from http://tn.gov/mental/health/recovery/2010_JointAnlRpt.PDF Mental Health Association of East Tennessee. (2011). Treatment Resources. Retrieved from http://www.mhaet.com/treatment-resources.php