You come home from a hard day at work and reach down to feed your cat. Pain suddenly shoots through your lower back, and though it doesn't radiate to your leg, it hurts. A lot. Where would you go for treatment?
Most people surveyed by a Washington State health insurance company answered exactly as you would expect: The emergency department.
Nationally, emergency departments handle more than 129 million visits a year, according to 2010 data from the National Center for Health Statistics. (http://1.usa.gov/1QPfluM.) But contrary to what many people believe, lack of awareness about the seriousness of their ailment is the underlying cause of the increase in emergency department visits, not the implementation of the Affordable Care Act (ACA).
Since the ACA rollout, 47 percent of emergency physicians reported a slight increase in the number of patients, and 28 percent reported seeing a significant increase in patient volume, according to a recent poll from the American College of Emergency Physicians. A majority of responders reported little to no reduction in the volume of emergency visits resulting from the availability of urgent care centers, retail clinics, and telephone triage lines. More than half of emergency physicians (56%) said the volume of Medicaid patients is up, and 70 percent said they fear their ED is not adequately prepared for increased patient volume. Simultaneously, 83 percent said they have concerns about efforts being made to reduce emergency visits, particularly those that will delay medical care or send patients to a less-skilled site (44%). (http://bit.ly/1IfoW9K.)
One study found, however, that the ACA may actually be decreasing ED visits. That paper sought to evaluate the effect of the ACA provision that lets parents claim their adult children as dependents until they are 26, and it found a statistically significant yet moderate decrease in ED use, with the quarterly visit rate down by 1.6 per 1,000 population. (Ann Emerg Med 2015;65:664.)
“The thing that was interesting was that the decrease was concentrated among visits due to preventable conditions or conditions that could be treated in outpatient settings. That implies that once they got insurance, young adults were able to use medical care more efficiently and reduce their visits to the ED,” said Asako Moriya, PhD, a study author who works for the Agency for Healthcare Research and Quality. Dr. Moriya said it's important to keep in mind, however, that this study focused on only one particular provision, and she couldn't predict what would happen in other populations.
Reducing ED Use
Washington State data show that certain efforts can reduce ED visits, too. Group Health Cooperative of Puget Sound (GHC), a nonprofit that provides health care and insurance, and Service Employees International Union Healthcare NW Health Benefits Trust (SEIU), formed a partnership that delivers health benefits to home health care workers, reducing emergency department use among a small portion of the trust's membership by 27 percent over four years.
The collaboration involved a four-pronged strategy implemented over time, starting with a $100 cash incentive if workers completed four steps, which evolve each year. These have included signing up for an online platform where they can email physicians, order prescriptions, and access health information and self-help resources, complete a health risk assessment, and complete preventive primary care and dental appointments. The next strategy was increasing an ED co-pay from $75 to $200, while an out-of-pocket urgent care charge remained at $15.
Copays, meant to reduce visits, work because the money comes out of the patient's pocket. The Centers for Medicare and Medicaid Services increased the maximum allowed amount for Medicaid ED copayments to $8 in 2013. California also submitted a waiver for a raise to $15 for nonemergency use of the ED for Medicare recipients, and Florida submitted a proposal for $100. (Health Econ 25 Jan 2015; doi: 10.1002/hec.3164; http://bit.ly/1Le64hm.) These proposals have not been implemented, but they assert the interest states have in using cost sharing to discourage nonemergent ED use among Medicaid populations. The results of this study supported GHC's and SEIU's strategy to increase the co-pay, finding that “copayments for nonemergent use of the ED may be successful at deterring visits for nonurgent conditions.”
GHC and SEIU also introduced a social media campaign to educate the home health care workers in their plans about the proper use of the ED and the difference between urgent and emergency department care. The partnership also made a point of reminding workers of the locations and hours of urgent care centers and how to schedule appointments with urgent care physicians and reiterated that patients could consult GHC's 24-hour nurse advice line.
Moving to Managed Care
The first step before implementing these efforts, however, was to move the plans' 13,500 patients from a fee-for-service health plan into a managed care environment. The population, for the majority, was female, minority, between 46 and 64, and suffered from multiple chronic conditions.
“One of the principles of managing an ER is to make sure patients identify with and bond with not only a doctor but with a delivery system,” said Ric Shepard, MD, the medical director of care management for GHC.
What that means, he said, is that patients should have a primary care physician who needs to deliver on the promise of access and to make sure people are bonded to what the delivery system has to offer as an alternative to an emergency department.
Take this example: The company sent patients postcards after any initial ED visits to tell them the insurer would reach out by phone to discuss other options, like GHC's 24-hour nurse line and the network of owned, operated, and contracted urgent care centers throughout the state. GHC was able to reach three-quarters of patients by phone, but even for the remaining members who couldn't be reached, ED visits went from 0.41 visits per member per month to about 0.21 visits per member per month, a 49 percent decrease.
These initiatives are benefitting patients as well as GHC and SEIU because individuals who receive care from a primary care physician are likely getting coordinated care, said Cheryl Strange, the senior director of operations for the SEIU Health Benefits Trust. “ER care is appropriate for many situations but generally not great as a default. The patient may be subject to duplicative procedures that may not be necessary, which adds time, cost, and discomfort to their lives,” Ms. Strange said.
“ER care is far more expensive per episode than non-ER care. It is more costly to the individual, the health plan, and to the purchaser,” she said. “There is no added value for this level of care in non-emergency situations yet the various purchasers [the patient, the health plan, the purchaser] must pay this high price.”
GHC and SEIU declined to provide any data that support the benefits to patients, however, explaining that they used a relatively small series and it wasn't a randomized, controlled trial, Dr. Shepard said.
Is Access the Answer?
Still, will access to a primary or urgent care center be enough to reduce ED visits? “People nowadays want what they want when they want it. There's a lot of demand that has to be met so people have to be able to come up with alternatives within the health care sector to meet that demand. Otherwise, they're going to go where they know they're going to get the right care,” said Jon Mark Hirshon, MD, MPH, PhD, a professor in the departments of emergency medicine and epidemiology and public health at the University of Maryland School of Medicine and the senior vice chair of the University of Maryland, Baltimore's institutional review board.
Reducing visits is one thing, but maintaining that reduction relies on the accessibility patients have to primary care, he said. Factors that affect availability include a primary care physician's hours, availability on weekends, whether he can squeeze the patient into the day's schedule, and the potential immediacy for lab and imaging results.
“My colleagues and I all have had patients who told us that they had called their doctor's offices for an appointment. Then they were told it would be many days or a couple of weeks before they could get seen. So they came to us because their health care need couldn't wait. The patients knew that they would get the care they needed right away, including all necessary labs and imaging. Definitely not something they would get in their doctor's office,” said Dr. Hirshon, who also added that he does not think the goal should be to reduce ED visits.
“There are incredibly efficient and effective ways of delivering care. Appropriate use of health care resources is what needs to be discussed. And that includes appropriate and adequate primary care,” he said. “First of all, from the individual perspective, we need to get better care coordination so that when people come we make sure there are adequate resources for follow-up, and there's a case manager. I've been around long enough to remember when we had social workers in the ED and then they took them all out because they were too expensive. And now they're putting social workers and case managers back in because they realize that without that care coordination, these individuals aren't able to navigate the health care system and aren't able to get the care they need.”
It's Not a Bird, It's Not a Plane — It's a Superuser
The strategies put forth by Group Health Cooperative of Puget Sound (GHC), a nonprofit that provides health care and insurance, and Service Employees International Union Healthcare NW Health Benefits Trust (SEIU) to reduce emergency department visits was targeted at a special one percent of the patient population — the superuser. They account for about one-quarter of the United States' health care disbursement.
The top percent of ED users ranked by their health care expenses accounted for 21.4 percent of total health care expenses in 2010, with an annual mean expenditure of $87,570. The lower 50 percent of Americans, in comparison, accounted for only 2.8 percent of the total, according to an August 2013 statistical report by the Agency for Healthcare Research and Quality (AHRQ). (http://1.usa.gov/1MLJzOO.)
These superusers are young and old, insured and uninsured, and tend to have complex and complicated medical issues. They all have things in common, though, like the lack of the social networking that can help them coordinate their care after their release. Specifically, most don't have a regular physician who can provide ongoing primary care.
“And it's the lack of appropriate or adequate kind of management of those issues. So they're coming in and they need to come in in many instances, but are there ways we can improve their management so they don't need to come in?” asked Jon Mark Hirshorn, MD, MPH, PhD, a professor in the departments of emergency medicine and epidemiology and public health at the University of Maryland School of Medicine and the senior vice chair of the University of Maryland, Baltimore's institutional review board.
The GHC and SEIU four-pronged strategy to reduce emergency department visits ensures emergency department access to a customized care plan formed in collaboration with the patient's physician, integration of mental health care, and instant notification of primary care providers when enrolled patients arrive in the emergency department. As a result, superusers' emergency department visits fell 37 percent, with initial Medicaid savings exceeding $33 million, according to multiple news outlets.
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