"Avoidable ER Visits” Can Be Solved by Innovative Frontline Care

Updated: May 30, 2018

May 28, 2018

Albert DiPiero, MD, MPH Chief Medical Officer and Cofounder ZOOM+Care

Dave Sanders, MD CEO and Cofounder, ZOOM+Care

Take Home Points:

  1. Faster care is better, safer and cheaper

  2. Get care in the lowest cost setting first

  3. Give people/patients credit - they can tell a true life-threatening emergency

In their May 19, 2018 article in the New York Times (Avoidable’ E.R. Visits, Patients and Doctors Push Back), Reed Abelson, Margot Sanger-Katz and Julie Creswell document the fumbling attempts of Anthem, one of the nation’s largest health insurers, to control healthcare costs. Anthem has revived an old and dreaded policy of denying payment for patient visits to the hospital emergency department if, in retrospect, the diagnosis listed on the insurance claim turns out not to be a “true emergency.”

At one level it is completely understandable that Anthem would focus on ER visits. There is incontrovertible evidence that misuse of the ER is one of the largest waste streams in the US healthcare system. In a famous 2007 white paper (A Matter of Urgency: Reducing Emergency Department Overuse A NEHI Research Brief – March 2010 ), the misuse of U.S. emergency departments was documented responsible for $38 billion in wasteful spending each year. The cost of this waste has likely only increased since then.

But playing Monday morning quarterback and refusing to “cover” the visit when the diagnosis turns out to be a non-life-threatening conditions simply hurts patients who cannot afford $2,000+ out-of-pocket unanticipated bills.

What has caused this mess?

The ER is symptomatic of the triple failure of US healthcare: cost failure, care failure, and experience failure. We have failed at controlling costs: Americans spent an astounding $3.4 trillion on healthcare in 2016 (2017 March - HEALTH AFFAIRS VOL. 36, NO. 3:National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy). This spending represents 17.9 percent of our gross domestic production. We have failed at the delivery of care: despite such impressive spending, the health of the nation is below that of all other western countries, and we are less healthy that many smaller, less developed days, by many population health care measures. And we have failed to deliver a great experience: Getting care has become an increasingly unpleasant, bureaucratic and demeaning experience. In comparison, transportation, shopping, entertainment and numerous other industries have become revolutionary experiences due to break-through services that focus on the consumer and unleash the power of the individual.

We must acknowledge that insurers, healthcare providers and government are all complicit in the drive to wasteful spending:

Insurers erect barriers to receiving care in diverse settings such as telemedicine, urgent cares, primary care offices, and retail clinics. In their drive to narrow networks and in a misguided belief that all access to care is wasteful, they limit selection of less expensive settings and then put up further roadblocks, such as requiring “prior authorizations for important tests such as CT scans when these tests are performed outside of the ER. Insurer negotiations also drive the lowest cost, small practices out of the market, leaving the large integrated delivery systems with ERs ruling the market and obtaining the highest reimbursements.

Providers must also examine themselves. They are self-serving in pushing care to the highest cost, most intensive setting. As the article by Abelson and colleagues notes, the ER “functions as the front door to most hospitals…”. The ED serves as the main entry point for patients admitted to the hospital and as such is a fiercely defended revenue stream for the hospital. Hospitals and physicians have no incentive to limit the use of the ER.

Finally, government locked in the ER as the preferred site for frontline care. Through a series of intentional and unintentional policies both state and federal governments push people to the most expensive setting for care: by limiting emergency care to hospital based ERs, governments play into the desires of hospitals to protect their goose that lays the golden egg. At the federal level, longstanding payment policies for Medicare and Medicaid - which are copied by commercial insurers - structurally limit payment to primary care providers, care via telemedicine, nurse practitioners, naturopathic physicians, and physician assistants, all of whom could provided initial care in less intense, less expensive settings. The result is not surprising: patients go to the ER for their acute, urgent symptoms.

But there is a solution to this spiral of cost and waste: embrace innovation and open up care to settings and by providers that can provide the best care at the lowest cost. Faster care is better care, safer care and cheaper care. Care could begin with a telemedical visit and then be bumped up to an in-person visit at an efficient retail clinic or primary care office in the neighborhood. From their patients requiring more intensive levels of care can be sent to urgent cares or clinics that provide emergency services outside of the hospital ER. Theses settings are safe and deliver care faster and at a lower cost. But this will succeed only if insurers and government appreciate the growing diversity of care settings, quit cowering to the status quo players and also trust patients to make wise and appropriate decisions.

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