6 Steps To Impacting Medicaid ER Utilization

Posted by Alicia MacLeod on Oct 25, 2018 2:46:47 PM


There was once an assumption that the expansion of Medicaid would yield recipients consuming more primary care services rather than seeking out the Emergency Room as their first stop in health care decisions. Several years after the inception of the Affordable Care Act, we’ve learned this is not the case. A recent Washington Times article pointed out that Medicaid expansion has, in fact, not pushed those using Medicaid benefits to PCPs, rather it has increased the traffic to emergency rooms. So, why are Medicaid recipients two times as likely to seek out care at the emergency room rather than a lower-cost option or using their primary care provider? Simply put, it comes down to benefit design, education, and ultimately consumer engagement. In populations like Medicaid, where benefit design and education on health care consumption are not widely understood or properly communicated, there is poor engagement, which perpetuates inappropriate benefit use. 

This can change and there are examples of appropriate use of health care benefits that leads to reductions in utilization of emergency rooms. Ultimately, this has occurred in markets where payers, community health organizations, and health systems have focused on the right consumer engagement, benefit design, and education strategies. These organizations have built engagement strategies that encompass both proactive and reactive activities centered around the consumer. Education on key chronic conditions and urgent care options have ultimately led to overall reductions in cost from the emergency room.

These strategies include:

  1. Making socio-economic resources part of the discussion (i.e. community health centers, etc.)
  2. Making other services more readily available (such as telehealth and urgent care)
  3. Targeting outreach to the right population (i.e. new members and frequent utilizers)
  4. Developing multi-channel programs (one size doesn’t fit all)
  5. Properly timed education on the proper use of benefits (such as the emergency room)
  6. Benefit designs that promote proper use of benefits (i.e. removal of copays for urgent care)

For education specifically, Medicaid recipients want resources in which to ask their questions when they don’t understand where to go for health care or how to get there. To drive the right health care utilization and ultimately reduce inappropriate emergency room visits, it takes much more than just a handout during benefit enrollment or a voicemail speaking about their benefits in a language they don’t understand. This is why payers and others are shifting to an environment that gives consumer options on where to ask questions for accessing care. 

It’s a known fact that consumers like talking with a trusted resource when it comes to understanding their options for care, especially in urgent situations. Nurses are most definitely that trusted voice and with the right engagement strategy, are an effective solution. To find out more on how Citra’s Nurse Advice Line can be an effective Medicaid engagement strategy that impacts ER utilization, download Citra’s catalog here:

Download Nurse Advice Line Catalog

Alicia MacLeod

Written by Alicia MacLeod

Alicia MacLeod is Regional Vice President at Citra. Alicia has 20 years of experience working with payers and population health organizations. She specializes in health plans on population health and member engagement strategies for Commercial, Medicare, and Medicaid in the national and regional health plan markets.

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