Common use of Emergency Room Clause in Contracts

Emergency Room. For the outpatient hospital emergency room service category and the corresponding physician emergency room visits category, we reviewed the following: (1) CY 2016 managed care utilization levels for each MCP and (2) the resulting classification of claims using the NYU Center for Health and Public Service Research (CHPSR) Emergency Department Algorithm. The NYU CHPSR tool classifies emergency room utilization into four (4) primary categories as well as categories that are excluded from the grouping. The four categories include: Non-emergency, Emergency/Primary Care Treatable, Emergency–Preventable/Avoidable, and Emergency–Not Preventable/Avoidable. Subsequent to the review of the experience into these defined categories, we developed specific adjustments for the first three categories to reflect the target utilization levels for the managed care plans. The following illustrates the adjustments by emergency room classification:  Non-emergency – 20% Reduction  Emergency/Primary Care Treatable – 10% Reduction  Emergency – Preventable/Avoidable – 5% Reduction When applying the adjustments listed above, reductions were taken from level 1 emergency room claims first, followed by level 2 and level 3 claims if applicable. No adjustments were made to level 4 or level 5 emergency room claims. In coordination with determination of the managed care adjustments for hospital outpatient emergency room services, we assumed that most emergency room visits reduced would be replaced with an office visit. The utilization of professional office visits and consults was increased proportionately. Inpatient Hospital We applied managed care adjustments to base year utilization to reflect higher levels of care management relative to the CY 2016 experience period. We identified potentially avoidable admissions using the AHRQ prevention quality indicators (PQI). We also analyzed the frequency of re-admissions for the same DRG. Inpatient hospital managed care adjustments were developed by applying assumed reductions to potentially avoidable inpatient admissions and same-DRG readmissions. This analysis was completed at the population and regional level. Our analysis was completed at the regional level by first reducing readmissions within 30 days, and then reducing non- readmissions for select PQIs. Inpatient hospital managed care adjustments were developed by applying a 10% reduction to same-DRG readmissions and a 5% reduction to potentially avoidable inpatient admissions. In completing our analysis, we estimated inpatient hospital unit cost changes based on the utilization reductions outlined above. No adjustments were made to corresponding inpatient physician charges to account for the potential shift of these services to an ambulatory setting. Additionally, nursing facility claims were excluded from this analysis.

Emergency Room. For the outpatient hospital emergency room service category and the corresponding physician emergency room visits category, we reviewed the following: (1) CY 2016 2015 managed care utilization levels for each MCP and (2) the resulting classification of claims using the NYU Center for Health and Public Service Research (CHPSR) Emergency Department Algorithm. The NYU CHPSR tool classifies emergency room utilization into four (4) primary categories as well as categories that are excluded from the grouping. The four categories include: Non-emergency, Emergency/Primary Care Treatable, Emergency–Preventable/Avoidable, and Emergency–Not Preventable/Avoidable. Subsequent to the review of the experience into these defined categories, we developed specific adjustments for the first three categories to reflect the target utilization levels for the managed care plans. The following illustrates the adjustments by emergency room classification:  • Non-emergency – 20% Reduction  • Emergency/Primary Care Treatable – 10% Reduction  • Emergency – Preventable/Avoidable – 5% Reduction For claims incurred during the October through December 2015 time period, the NYU CHPSR tool was run after down coding ICD-10 codes to ICD-9 codes. We utilize the General Equivalence Mappings9 (GEMs) produced by CMS to map ICD-10 codes to ICD-9 codes; however, the GEMs process is not designed to create one-to-one mappings. In order to force a one-to-one mapping, we use an empirical member frequency count from a large claims dataset to select the most appropriate match. When applying the adjustments listed above, reductions were taken from level 1 emergency room claims first, followed by level 2 and level 3 claims if applicable. No adjustments were made to level 4 or level 5 emergency room claims. In order to avoid potential overlap with prospective program changes, no adjustments were applied to outpatient emergency room claims three days prior to an inpatient admission. In coordination with determination of the managed care adjustments for hospital outpatient emergency room services, we assumed that most emergency room visits reduced would be replaced with an office visit. The utilization of professional office visits and consults was increased proportionately. Inpatient Hospital We applied managed care adjustments to base year utilization to reflect higher levels of care management relative to the CY 2016 2015 experience period. We identified potentially avoidable admissions using the AHRQ prevention quality indicators (PQI). We also analyzed the frequency of re-admissions for the same DRG. Inpatient hospital managed care adjustments were developed by applying assumed reductions to potentially avoidable inpatient admissions and same-DRG readmissions. This analysis was completed at the population and regional level. Our analysis was completed at the regional level by first reducing readmissions within 30 days, and then reducing non- readmissions for select PQIs. Inpatient hospital managed care adjustments were developed by applying a 10% reduction to same-DRG readmissions and a 5% reduction to potentially avoidable inpatient admissions. In completing our analysis, we estimated inpatient hospital unit cost changes based on the utilization reductions outlined above. No adjustments were made to corresponding inpatient physician charges to account for the potential shift of these services to an ambulatory setting. Additionally, nursing facility claims were excluded from this analysis.

Emergency Room. For the outpatient hospital emergency room service category and the corresponding physician emergency room visits category, we reviewed the following: (1) CY 2016 managed care utilization levels for each MCP and (2) the resulting classification of claims using the NYU Center for Health and Public Service Research (CHPSR) Emergency Department Algorithm. The NYU CHPSR tool classifies emergency room utilization into four (4) primary categories as well as categories that are excluded from the grouping. The four categories include: Non-emergency, Emergency/Primary Care Treatable, Emergency–Preventable/Avoidable, and Emergency–Not Preventable/Avoidable. Subsequent to the review of the experience into these defined categories, we developed specific adjustments for the first three categories to reflect the target utilization levels for the managed care plans. The following illustrates the adjustments by emergency room classification:  • Non-emergency – 20% Reduction  • Emergency/Primary Care Treatable – 10% Reduction  • Emergency – Preventable/Avoidable – 5% Reduction When applying the adjustments listed above, reductions were taken from level 1 emergency room claims first, followed by level 2 and level 3 claims if applicable. No adjustments were made to level 4 or level 5 emergency room claims. In coordination with determination of the managed care adjustments for hospital outpatient emergency room services, we assumed that most emergency room visits reduced would be replaced with an office visit. The utilization of professional office visits and consults was increased proportionately. Inpatient Hospital We applied managed care adjustments to base year utilization to reflect higher levels of care management relative to the CY 2016 experience period. We identified potentially avoidable admissions using the AHRQ prevention quality indicators (PQI). We also analyzed the frequency of re-admissions for the same DRG. Inpatient hospital managed care adjustments were developed by applying assumed reductions to potentially avoidable inpatient admissions and same-DRG readmissions. This analysis was completed at the population and regional level. Our analysis was completed at the regional level by first reducing readmissions within 30 days, and then reducing non- readmissions for select PQIs. Inpatient hospital managed care adjustments were developed by applying a 10% reduction to same-DRG readmissions and a 5% reduction to potentially avoidable inpatient admissions. In completing our analysis, we estimated inpatient hospital unit cost changes based on the utilization reductions outlined above. No adjustments were made to corresponding inpatient physician charges to account for the potential shift of these services to an ambulatory setting. Additionally, nursing facility claims were excluded from this analysis.