Complaining of abdominal discomfort and chronic bronchitis, Toshia Johnson, 22, an unemployed mother on Medicaid, went to a hospital emergency room in Bend, Ore., more than two dozen times in the year that ended in June 2010. She was never admitted to the hospital and used the ER for routine care because, she says, it's near her home, and the care was free.
But in the first six months of this year, after entering a state-funded program designed to reduce unnecessary ER use by Medicaid patients in central Oregon, Johnson has gone to the ER just once, after breaking her tailbone.
In the first half of this year, ER visits by the 400 patients in this program have declined by more than half from the same period last year, saving Medicaid $1 million, officials say.
Efforts to reduce unnecessary ER visits by patients in Medicaid, the joint state-federal health program for the poor and disabled, are proliferating as states search for ways to control the soaring costs of the program.
But state officials complain that their efforts are sometimes hampered by hospitals' aggressive marketing of ERs to increase admissions and profits.
"Many hospitals are actively recruiting people to come to the ER for non-emergency reasons," said Anthony Keck, South Carolina's Medicaid director, citing facilities that tout their speedy ER service on highway billboards.
Officials at HCA, the nation's largest for-profit hospital chain, and other hospitals reject the assertion that marketing the efficiency of their ERs attracts patients who don't belong there.
"That is certainly not our intention," said Mark Foust, a spokesman for HCA's Virginia division, which owns 12 acute-care hospitals.
Medicaid officials in Washington state were so concerned by hospitals' ER marketing that they issued new rules making it harder for hospitals to qualify for Medicaid bonus payments if they promote their ER for primary care.
"They sure don't help us when we are trying to get word out that the ER is not the place you go for primary-care diseases like treating asthma or diabetes," said Jeffrey Thompson, chief medical officer for the state Medicaid program.
Saint Agnes Hospital in Baltimore estimates that about 20 percent of its Medicaid and uninsured ER visits in 2008 were for "non-emergent" reasons. Using a $1 million federal grant, the hospital has been working since 2009 to divert patients needing more-routine care to a community health center located on the hospital's campus. The health center is less costly because it has much lower overhead costs than the hospital, which must be staffed around the clock.
Some states are changing how they pay for ER care and requiring Medicaid patients to pay more out of pocket. Washington state this year will stop reimbursing hospitals for treating a Medicaid recipient for non-emergency care in the ER after the third such visit.
Pending federal approval, Florida will charge Medicaid recipients $100 for using the ER for routine care.
The American College of Emergency Physicians thinks government efforts to divert Medicaid patients from ERs are misguided.
"Most emergency patients are seeking emergency care appropriately," said Sandra Schneider, president of the American College of Emergency Physicians.