How providers can stop driving patients to the emergency room
Navigating through care options as a patient can be confusing. Not only is it difficult to decide which care setting to choose, but a lack of information and guidance forces patients to make the difficult – and expensive – decision themselves.
When left with the decision themselves, nonurgent patients are choosing emergency departments (ED) more than any other available option.
According to the U.S. Centers for Disease Control and Prevention, 145.6 million people visited their emergency department in 2016. Of them, 42.2 million people went for injuries, 12.6 million people were admitted and 2.2 million were admitted to a critical care unit.
As the industry continues to shift toward value-based care, curbing readmissions continues to be a problem. One in five Medicare patients are readmitted within 30 days of discharge; about one in four patients over the age of 65 with a chronic condition are readmitted within a 30-day span.
With such a high volume of patients choosing to go to the emergency department over alternatives such as their primary care physician (PCP) or urgent care, providers need to get to the root of this problem – and it starts with patient education.
Why people go to the ED for nonurgent care
Most studies find that at least 30% of all ED visits in the U.S. are nonurgent, though other research reports lower numbers. Data has gone back and forth as to whether ED visits for nonurgent care have declined or increased, but the U.S. Centers for Disease Control and Prevention (CDC) found that nonurgent ED use grew from 4.3% in 2014 to 5.5% in 2015.
Dr. Andrew Wagner, Chief Clinical Officer at DispatchHealth, a mobile healthcare provider that brings acute care to the patient, believes that the reason for such high volume of nonurgent matters ending up in the ED is because of how complex the entire situation can be.
“Providers tend to ask patients to make an educated decision on their presented symptoms and how sick they are. It’s very difficult to make that decision on your own,” said Dr. Wagner. “Then, you have to layer on top of it the issue of accessibility. The patient has to consider what type of insurance they have, what is in or out of network…it’s really complex.”
“By delivering acute care to people of all ages in the comfort of their home, DispatchHealth helps reduce unnecessary emergency room visits and hospitalizations, improve clinical outcomes and decrease burdensome costs for the overall healthcare system.”
It has been widely reported that people use the ED in place of going to a PCP. Up to 27% of all ED visit cases could be treated at a retail pharmacy or urgent care center, which would save about $4.4 billion annually, one study found. In states that expanded Medicaid coverage under the Affordable Care Act, there were 2.5 more emergency department visits per 1,000 people after 2014 while ED visits from uninsured people went down 5.3%.
“Think of yourself when you’re sick or injured. Your perception can be that you’re very sick and you believe you need to be seen immediately – whether it’s really an emergency or not,” Dr. Wagner said. “The question becomes ‘What is the easiest way for me to be seen and not have to deal with follow-up appointments or anything else?’ That tends to be the emergency department. If you go there, you feel like you have access to the entire health care ecosystem, just in case.”
Social determinants also impact a patient’s decision to head to the ED compared to an urgent care clinic or their PCP. A 2019 study found that rural ED rates went up by more than 50% compared to urban ED visits over a 12-year period.
On the flip side, many patients say it’s difficult to access outpatient care. One report found that up to 32% of nonurgent ED patients tried to get in touch with a PCP prior to going to the ED. Other research on patients who seek care from EDs found that 68% wanted a PCP and 48% made attempts to secure a PCP.
“It’s no secret that primary care physicians are busy. If you’re trying to get a same-day appointment, it is very difficult. Even as a doctor, it’s difficult for me too,” said Dr. Wagner. “Then you’re left with a decision. Do I wait? Is it ok that I wait? Do I spend a couple weeks going from my primary care physician to specialty care, to imaging, to labs and have this take multiple weeks? Or do I just get it all done at the ED?”
What it means for hospitals
Because so many ED visits are avoidable, the costs are higher, and the strain on emergency-trained professionals can be prevented, it only makes sense for hospitals to try to educate people on being more selective before automatically going to the hospital.“Providers tend to blame the patients for mistriaging themselves based on hindsight and don’t necessarily consider the challenges that patients have figuring out where to go,” according to Dr. Wagner.
Taking the time to enact protocols or devise educational campaigns that target repeat visitors may be able to alleviate some of the pressure that unneeded ED visits put on patients, insurers and hospitals.
“Building a solution that addresses the root cause of why the patient ends up in the ED is critical to fixing this issue. When acute needs occur, options can be limited. We need to be able to understand that there may be multiple factors at work leading to the decision to go to the ED. There could be some social determinants of health that causes the patient to rely on the ED – like using an ambulance as the only way to be transported to a provider.”
By improving patient engagement and education, providers not only save time and resources, but it can also lead to a decrease in cost. A UnitedHealth Group study found that the healthcare system could save $32 billion a year by diverting “avoidable” ED visits by privately insured patients to primary care or urgent care facilities. Avoidable conditions included bronchitis, cough, dizziness, flue, headache, low back pain, nausea, sore throat, strep throat and upper respiratory infections.
Interventions: What works, what doesn’t
Targeting patients who are looking for a PCP or urgent care clinic—as well as frequent ED visitors—have been effective interventions for better routing patients for nonurgent care.
DispatchHealth, which treats the majority of the ailments listed in the UnitedHealth Group study with a mobile solution, has found success deploying care on the patient’s terms in the comfort of their own home. As a substitution for the emergency room service, DispatchHealth provides a seamless care experience and shares a detailed report with each patient’s living community, home health agency and/or primary care physician.
At Memorial Hermann Health System in Houston in 2008, health workers offered alternatives for care, connecting patients to medical homes and other services. Interventions such as those have found that individual case or care management had the most rigorous evidence base and yielded moderate cost savings, but saw variable reductions in frequent ED use.
Hospitals and clinics will have to better implement these processes and educational messages, because readmission through programs such as Bundled Payments for Care Improvement Advanced (BPCI Advanced) along with other payment models will reward medical centers focused on value-based care.
Although interventions have given us insight into how to better route patients for nonurgent care, plenty of work can still be done to ensure that EDs are utilized appropriately. At the same time, ED’s will continue providing costly care to patients with nonurgent issues. The only way to stop the bleeding is to help patients find—and utilize—the right solutions for their symptoms.