Highlight : Overuse of the Emergency Room

Overview

If you are experiencing a sudden and serious medical problem, the emergency room can be a lifesaver—sometimes literally. With its dedicated staff, crucial technology and array of services, the emergency room (ER) can be the place where patients are stabilized and treated so that they can begin to heal.

But too often patients go to the ER with problems that are not emergencies, such as respiratory infections, earaches or low-back pain. When simple medical concerns that can be treated easily and more cost effectively in a primary care setting or an urgent care clinic end up being treated in the ER, they contribute to waste in the health care system.

To measure potentially avoidable ER use, the Alliance uses a measure that includes over 330 ICD-10 codes for diagnoses associated with minor conditions that physicians agree can be safely and appropriately treated in a primary care setting. This is a conservative measure and likely underestimates the degree to which the ER is inappropriately accessed for care that can and should be treated in a less intensive environment.

These unnecessary visits add tremendous strain to the health care system and cost significantly more than visits to primary or urgent care. According to Healthcare Bluebook, an ER visit for a minor problem in Seattle can cost anywhere from $489 to more than $2,300. For a moderate problem, the cost can range from $982 to more than $4,750. By reducing overuse of the ER and seeking care in the appropriate setting, Washingtonians can save money, receive better care and make the health system more efficient.

Key Findings

• The 2017 Community Checkup shows that 12% of ER visits for commercially insured people in Washington state were potentially avoidable. For Medicaid enrollees, 18% of ER visits were potentially avoidable.
• Based on the Alliance’s database of commercially and Medicaid insured lives, nearly 140,000 visits to the ER were potentially avoidable in the latest measurement year. And since the Alliance’s database does not include everyone in the state, the actual number is even higher.
• There is wide variation among medical groups for rates of potentially avoidable ER visits. For all payer types across the state, medical group rates range from 5% to 25%.

Action Steps

There are many reasons people go to the ER when they don’t need to, including convenience or being uncertain about their health condition. However, there are steps that everyone involved can take to help make sure the ER is used for emergencies only.

• For purchasers: Provide your employees with objective information about the appropriate place for care and about the increased costs and risks of an ER visit. Align benefit designs to encourage employees to seek care outside of the ER for non-emergency problems.
• For providers: Educate patients about when it’s appropriate for them to visit the ER—and when it’s not. Offer timely appointments that reduce the need for patients to turn to the ER when they have an urgent health issue. Triage patients when they arrive at the ER and redirect them to urgent care or primary care if the ER setting is not necessary to treat their problem.
• For patients: Establish a relationship with a primary care provider who knows your medical history and who you are comfortable turning to for help. In addition, understand the extra costs and risks that come with being treated in the ER.
• For plans: Use financial incentives to promote visits to primary care or urgent care rather than the ER.

 

*At least 50% of patients attributed to this medical group are insured through Medicaid.

High-performing and low-performing lists exclude OB-GYN and other specialty group practices.