One of the big potential bonuses of healthcare reform was the idea that it would decrease the huge expense of unnecessary use of emergency rooms. However, a recent survey by the American College of Emergency Physicians found that 75% reported increases in ER visits since the Affordable Care Act went into effect.
Experts cite several reasons for this, including a shortage of primary care physicians, more physicians opting out of Medicaid, patients automatically using the ER for primary care and inability of low-income workers to take work off during regular office hours. Some—including Center for American Progress fellow Dr. Ezekiel Emanuel—have suggested that insurance coverage alone will not solve this problem.
Big expenses despite coverage
The overuse of emergency departments in the U.S. racks up a $38-billion tab every year, according to a 2010 research study conducted by the New England Healthcare Institute. The average cost of an ED visit is $580 more than an office-care visit. And ED use for non-urgent care is up in all payer and age groups, suggesting the assumption that increased coverage would help reduce unnecessary ED care might be a false premise.
A 2013 report from Truven Health Analytics found that more than 70% of 6.5 million ED visits from patients with employer-sponsored insurance were for non-emergency conditions. "Conventional wisdom has previously suggested that this issue was confined to Medicaid, Medicare, and uninsured populations, but our research shows that the privately insured population's use of the ER is avoidable approximately three-quarters of the time," said John Azzolini, director of practice leadership at Truven Health Analytics.
Avoiding the ED visit
Study results point to several drivers for ED overuse that could provide pathways to access that do not require an emergency room visit.
Increasing access to primary care services can reduce ED overuse by 56%, according to the New England Health Institute. Other services that have proven successful in improving access include physician office weekend hours, 24-hour access to physician telephone services and patient-centered home health care. Dr. Jeff Selevan, senior advisor to Southern California Permanente Medical Group, Kaiser Permanente, says they provide members with 24/7 nurse-advise telephone lines, and that primary physicians and specialists all have e-mail access and established standards for response times.
"For example, in Southern California (about 4 million members) there are several 'outreach' programs for members with chronic conditions that frequently lead to ED visits and hospitalization if not carefully managed," Selevan said. "Our heart failure disease management program, which published data many years ago, showed that they were able to significantly decrease 90-day readmission rates, ED visits, and mortality among patients they were managing."
Reducing ED overuse requires policy actions that involve providers, payers and patients. Again, Dr. Selevan says that integration is key. "If 'healthcare provider' means a group of physicians, integration means all physicians and the hospital share the same goals for clinical outcome and care delivery efficiency," Selevan said. "When the doctors and hospitals are successful in reducing unnecessary utilization and risk and rewards are shared among insurer, providers and hospitals, we have the essential elements to successful implementation of true integration."
Patient navigators
A recent pilot program by the Highmark Foundation and Accenture at three Pennsylvania hospitals utilized nonclinical patient navigators to help patients gain access to essential healthcare services. The navigators had to pass a three-day certificate program and then have specialized training for their assigned patient population at their designated location. They conducted patient follow-ups, connected patients to local care services and scheduled patient appointments.
Data collected from the pilots from July 2013 to March 2014 showed a 43% reduction in the non-emergency use of the ER and a 60% reduction in 30-day re-admissions for targeted diagnosis-related groups. The navigators helped to free up physicians and other clinical employees to focus on tasks that require their medical expertise. The success of the pilot has lead to the expansion of patient navigator training programs in 35 locations around the U.S., according to a statement by Accenture.
Addressing frequent ED users
Up to 28% of ED visits come from patients who frequent the emergency department four or more times a year, according to the Advisory Board Company. Regions Hospital, part of the HealthPartners system in St. Paul, Minnesota, saved $1.1 million in avoidable frequent user costs by creating a personalized care plan for each patient. The hospital reduced ED visits by 46% in this patient group when comparing utilization two months before versus two months after care plan implementation.
The program focuses on four types of frequent ED users, according to The Advisory Board: patients seeking narcotic pain medication, patients with borderline personality disorder, nephrology patients and patients with a history of avoiding medical treatment recommendations. It increases patient access to primary care by ensuring patients receive follow-up appointments, phone calls and letters from staff to help reinforce care plan goals. To improve coordination, care plans are hardwired into the EMR so providers across the system have access to timely, accurate summaries of patients' encounters and health barriers.
A multidisciplinary Hospital Care Plan Committee meets monthly to create new care plans and determine whether patients referred by other providers in the system are appropriate candidates. Regions Hospital's ED has established its own Care Plan Committee to support frequent ED users. Improved patient outcomes and reduced ED utilization have led to further changes in how the system approaches narcotic-seeking patients. Automation of narcotic prescriptions is limited and now requires a manual multi-step process. A policy prohibiting refills for "lost" narcotics has also been established.