JOHNSON CITY, TN (WJHL) – TennCare recipients cost taxpayers nearly $85 million by going to the emergency room for common colds, headaches, toothaches and other non-emergencies, according to the most recent available state data.

The data show federally and state-funded non-emergent ER visits resulted in a 25% increase in cost in the 2016 fiscal year compared to the prior year.

State records identified at least 126,000 visits in one year alone, including 24,257 visits for acute upper respiratory infections, 14,178 visits for headaches, 11,420 visits for strep throat, 10,115 visits for nausea with vomiting, 9,918 visits for lower back pain, 9,098 visits for viral infections, 8,323 visits for fevers and 8,161 visits for toothaches.

State Fiscal Year 2016
non-emergent diagnosis Number of claims  Expenditures
LOW BACK PAIN9,918$1,243,618
FEVER UNSPECIFIED8,323$1,467,868

(Division of TennCare)

“This is a long-term problem,” TennCare Chief Medical Officer Dr. Victor Wu said.

Dr. Wu said the state’s Medicaid program is trying to come up with a solution by working to convince its 1.5 million patients, which include low-income pregnant women, children, the elderly and people with disabilities, to get regular checkups with a primary care physician and not just go to the doctor when they are sick.

“Everyone needs to have a relationship with their primary care provider,” Dr. Wu said. “I think if we can begin to turn the tide more toward prevention and turn the tide more toward focusing on wellness I think that will help, in general, offload some of the challenges we see when people do get sick and where they need to go.”

In addition to that effort, Dr. Wu said TennCare is increasing patient interventions, including face-to-face meetings, phone calls, text messages and letters and working with hospitals to help direct patients through the proper path of care.

“I think we’re still trying to work through all different avenues and all different channels,” he said. “It is really challenging.”

TennCare also reports it implemented a new policy several years ago that caps the amount of money it reimburses hospitals at $50 per non-emergent ER visit, which incentivizes hospitals to better educate the public. However, the state’s own numbers show more education is needed, particularly in East Tennessee, which is responsible for more than $30 million of the total $84 million expense.

“It’s an opportunity,” Dr. Shari Rajoo said. “It also is a signal that there is definitely a misunderstanding of the purpose of the emergency room. I think we really have to reorient ourselves to the emergency room is for life or limb threatening situations and ‘Is this one of those situations? Can I wait until the morning?’”

Mountain States Health Alliance’s AnewCare Collaborative has spent the last several years trying to drive the message home that primary care is not only more affordable, but ultimately better for a person and society’s overall health. At the ER, doctors aren’t specialists in treating chronic health problems. Instead, they’re focused strictly on emergency care and often times, only have a snapshot of a patient’s medical history. AnewCare Collaborative President Paige Younkin said MSHA is also trying to give patients support so they can call their care coordinator for advice about how best to treat their health issue and avoid the ER altogether.

“The patient’s better off because their care if coordinated,” Younkin said. “There is, for lack of a better word, there’s a captain of their ship.”

The AnewCare Collaborative, led by both women, is targeting certain patient demographics, using disease-specific initiatives to spread the message and trying to make primary care and urgent care more convenient.

“We’re working on establishing easier scheduling, open scheduling, maybe looking at different hours, so that they’re more flexible, so the patient is able to go there instead of the emergency department,” Younkin said.

Even with all of these efforts, the chairman of the Tennessee Senate committee in charge of TennCare oversight said there is only so much the state can do.

“It really is troubling,” Sen. Rusty Crowe (R), District 3, said.

Like his counterpart in Congress Rep. Phil Roe (R), District 1, Sen. Crowe said states need flexibility too that will only come from federal healthcare reform.

“The federal laws restrict our hospitals with regard to what we can do with Medicaid patients,” Sen. Crowe said. “Untie our hands and let us do what we need to do at the state level.”

“I strongly agree that states need more flexibility in how they structure their Medicaid programs so first-class people aren’t receiving second-class care,” Congressman Roe said in a statement. “This is why we prioritized Medicaid reform as part of the American Health Care Act that will help move towards a health care system that lowers the cost of care and empowers patients so they aren’t relying on emergency rooms for primary care.”

Experts say non-emergent visits aren’t just costing taxpayers money and costing TennCare patients better care, they’re also tying up the ER’s critical service, which delays care for people who really need emergency help.

“It just increases the wait time,” Dr. Wu said. “We want to help shift them to more prevention and wellness as opposed to just acute sickness.”

MSHA said patients should contact their primary care office for most medical problems, including urinary symptoms, cough/congestion, flu, earaches, sore throats, migraines, fever, constipation, rashes, minor cuts and burns, regular physicals, prescription refills, vaccinations, screenings and advice.

Meanwhile, the health system said patients should use urgent care when “it is not an emergency, but waiting to see your primary care provider is not an option.” Urgent care facilities can order any necessary bloodwork and can assist with urinary symptoms, cough/congestion, flu, earaches, sore throats, migraines, fever, constipation, rashes, sprains, back pain, minor cuts and burns, minor broken bones or minor eye injuries, MSHA said.

MSHA said patients should go to the ER for chest pain, severe abdominal pain, coughing up or vomiting blood, severe burns, deep cuts or bleeding that won’t stop, sudden blurred vision, sudden difficulty breathing or shortness of breath that is not relieved by inhalers, sudden dizziness, weakness, or loss of coordination or balance, sudden, new numbness in the face, arm, or leg, sudden slurred speech, sudden severe headache (not a migraine), seizures and “any other condition you believe is life-threatening.”