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Report on Preventable Health Care Events Highlights Agency Work to Improve Medicaid Quality of Care and Reduce Costs

Anne Swerlick
August 2017

A recent report from the Florida Agency for Health Care Administration focuses on potentially preventable emergency room visits and hospital admissions to help answer the question, “What are we getting for our money?”

Recent news has been dominated by Congressional proposals to radically restructure Medicaid financing. Public discussion surrounding Medicaid has shed light on some stereotypes and misinformation. Medicaid is already highly cost-efficient and most Medicaid beneficiaries are satisfied with their care and have health outcomes comparable to those who are privately insured. This is particularly noteworthy since Medicaid disproportionately serves people in much poorer health with substantially fewer resources than those privately insured.

The agency’s report demonstrates the state’s valuable efforts to improve Medicaid quality of care as well as reduce costs. It focuses on “potentially preventable health care events (PPEs)” including hospital admissions, hospital readmissions and emergency department (ED) visits. The agency recognizes that, “although not all potentially PPEs can be avoided, PPE rates in populations can be used as a gauge regarding the failure to access primary care and the quality of care available.”

The report includes an analysis of managed care plan data from August 1, 2014 to July 31, 2015. Findings are broken out by age, eligibility groups, plans and regions. Here are a few highlights:

  • More than three quarters of all ED visits were identified as potentially preventable – meaning they might have been prevented with better access to primary care, improved medication management or better coordination of care.
  • For children, the top two conditions leading to potentially preventable hospital admissions were for upper respiratory conditions and gastroenteritis, nausea and vomiting. Almost one-third involved acute infections that might have been treated in a primary care setting.
  • For children, 36percent of potentially preventable hospital readmissions were due to mental health or substance abuse conditions that continued following a prior admission for these conditions.  Children were most often readmitted for bipolar disorder and major depression.
  • For adults, the top potentially preventable hospital admissions were for abdominal pain and chest pain. Over one-third involved a chronic illness where outpatient care management might have prevented the visit.
  • For adults, schizophrenia is the top condition leading to a potentially preventable hospital readmission.

Out of the state’s $26.4 billion Medicaid budget, more than $15 billion is allocated for Medicaid managed care. Mostly private for- profit insurance companies are responsible for providing managed care to more than 3 million Florida Medicaid beneficiaries —  primarily children — and thousands of beneficiaries with medically complex conditions.

The report is a terrific starting point for drilling down on the barriers beneficiaries face in trying to access needed care. But fundamental questions remain, such as:

  • Why are so many children with pneumonia and asthma requiring hospitalization?
  • Why are so many children with mental health conditions being re-admitted to hospitals?
  • Why are so many children and adults seeking care in emergency rooms for upper respiratory infections?

The stage is set for critically important follow-up work, including direct engagement of beneficiaries, providers and plans. We commend the agency for taking this evidence-based, common sense approach to improving health care for the most vulnerable Floridians.

 

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