Dive Brief:
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A new International Journal For Quality in Health Care report found only 3.3% of emergency department (ED) visits studies are avoidable.
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The researchers reviewed 115,081 records from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011 that represented 424 million ED visits for patients aged 18 to 64.
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The study found that alcohol abuse, dental disorders and depressive disorders were the top three ICD-9 discharge diagnoses. It also found the most common avoidable ED visits were for a toothache, back pain, headache, throat soreness or other symptoms/problems related to psychosis.
Dive Insight:
The study comes as payers are pinpointing EDs as an area where costs can be reduced. They want to discourage unneeded visits and direct patients toward other settings. But it's not just a matter of patients not knowing when they need emergency care. Sometimes people go to an ED because they don't have insurance or access to care.
The study authors Renee Y. Hsai and Matthew Niedzwiecki, who are both with the Department of Emergency Medicine at the University of California at San Francisco, defined “avoidable” as any ED visit that did not require diagnostic or screening services, procedures or medications or hospital admission.
Alcohol abuse, dental disorders and depressive disorders were the top three ICD-9 discharge diagnoses, with nearly 7% of avoidable visits connected to alcohol-related disorders and mood disorders, which EDs are not able to properly treat.
“Our most striking finding is that a significant number of avoidable visits are for conditions the ED is not equipped to treat. Emergency physicians are trained to treat life- and limb-threatening emergencies, making it inefficient for patients with mental health, substance abuse or dental disorders to be treated in this setting,” they said.
They suggested one way to reduce avoidable ED visits is to address healthcare system gaps, including increasing access to mental health and dental care. The researchers said the findings should “serve as a start to addressing gaps in the U.S. healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits.”
States and payers have been taking a harder look at ED visits as a way to reduce healthcare costs. The Deficit Reduction Act of 2005 allowed states to “impose mandatory cost-sharing for non-urgent ED visits for Medicaid patients.” Indiana recently implemented copays for non-emergency care in an ER, which was part of the state’s 2015 Medicaid expansion waiver.
On the private payer side, Anthem, which is a major Blue Cross insurance provider, recently announced it is no longer covering unnecessary ED visits in Missouri. The insurer already has the same policy in Kentucky and Georgia, and may expand further to more states. Anthem said a company medical director reviews ED claims information from those states and decides whether symptoms and diagnoses warranted an emergency visit. Anthem said the company has denied a small percentage of ED claims since the policy first took effect in Kentucky in 2015.
Anthem, which also recently said it plans to stop paying for MRIs and CT scans performed on an outpatient basis at hospitals, is looking to push patients to get care in less costly settings rather than a hospital, including urgent care centers and freestanding imaging centers.
Hospital executives are concerned what those changes could mean for their facilities, especially if other payers follow Anthem’s approach. The American College of Emergency Physicians (ACEP) said Anthem’s ED policy is a “clear violation of the national prudent layperson standard,” which requires payers to cover patients based on a patient’s symptoms and not their final diagnosis.
ACEP added that nearly 2,000 non-urgent diagnoses on Anthem’s list of possibly non-covered symptoms can be life-threatening or lead to further health problems.
"Health plans have a long history of not paying for emergency care," said Dr. Rebecca Parker, president of ACEP. "For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice."
The issue for hospitals is not just a financial one, but a concern that patients may delay getting care because of the new ED policy.
"If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance," said Parker. "The vast majority of emergency patients seek care appropriately, according to the CDC, and often times should have come to the ER sooner."