Sara Tracy, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado, describes a formula for identifying high utilizers of the ED.
Resource intensive members --- they have also been called “frequent fliers” --- are classified as our high utilizers. High utilizers are members who are identified as low, medium or high. Our low members are those that had two ED visits in three months, our medium were those that had either three, four or five visits in six months and our ultra-high utilizers were those that had six or more visits in a year. We did a data pull based on claims data that helped to identify those that had a connection with either chemical dependency, behavioral health or no connection at all. Our data pull included information on the primary care physician (PCP), the EDs they’ve visited including the dates and the diagnosis, the top prescriptions that were prescribed for the member and the dollars that were spent on these members.
We identified approximately 1,000 members that fall within these guidelines. The first group we looked at was those individuals that have a known association with chemical dependency. Those are members who have had a referral or a visit with someone in our chemical dependency department within the last year. Many, if not most, of these members were patients who had issues with narcotics. We pulled a chart review of 25 members to identify those that had a current narcotics contract --- an agreement between the physician that’s prescribing the narcotics and the patient on the parameters for the prescription. Often, these members would request early refills; they may show up to the ED in pain requesting IV narcotics, so the narcotics contract is very critical to helping keep these members compliant. In our review, we found that only 20 percent of that population had a contract. When these members subsequently show up in the ED and there’s no contract, the ED does not have much guidance in how to treat this member.
We reviewed our current narcotic contract format and decided that it was very lengthy, rather robust and not user-friendly. We have worked with our chemical dependency department to revise that contract so that it is a one-page contract. It is very succinct and it includes 10 bullet points that the member initials, and it has all the parameters under which the physician will prescribe narcotics for that patient.