Emergency Department (ED) visits are common – and costly – in the United States. The CDC reports about 40 emergency room visits for every 100 people. The reasons range greatly and include headaches, chest pains, stroke, burns, difficulty breathing, trauma, and injury.
Not every ED visit can be avoided, but many can. According to the Agency for Healthcare Research and Quality, an estimated 13 to 27 percent of ED visits in the U.S. can be managed in physician offices, clinics, and urgent care centers, which would save $4.4 billion annually.
An Office of Health Policy report to Congress identified some strategies which have been shown to reduce unnecessary ED visits:
- Focusing on “superusers,” or individuals who make frequent, recurring visits to the ED for complex and recurring health needs, such as chronic conditions or mental health or substance use disorders, addressing their social needs, such as housing or employment, which may be preventing them from seeking proper care and treatment.
- Expanding access to primary and preventative care, such as connecting an individual to a primary care provider, as they may not have one.
- Leveraging CMS’ CMMI models, such as the Accountable Care Model. While not all of them measure ED visits, some do, and this is worth exploring.
Patients don’t always recognize the value of primary care
Primary care offers cost-effective care for everyday health issues, such as disease prevention, acute and chronic diagnosis, treatment, and care management. A primary care provider can assist patients with asthma, diabetes, and congestive heart failure, among other common conditions. However, many barriers prevent patients from accessing their primary care, such as transportation issues or work obligations.
A 2016 report found that the majority of non-urgent ED use occurs for the following reasons:
- Patients lack awareness of other healthcare sources
- Patients assume their condition is too serious for a primary care provider
- Patients believe that the ED provides more comprehensive services than their primary care physician
So how can health plans encourage their members to choose primary care providers for non-emergent needs? One study found that cash incentives for low-income members could help. With a $25 incentive, this study found that seventy-four percent of adults visited their PCP. Another option is creating a wellness incentive program, which rewards members for healthy behavioral activities, such as visiting their PCP on an annual basis.
Addressing SDoH can reduce ED visits in high-risk populations
A recent study published in Annals of Emergency Medicine evaluated the relationship between social determinants of health and emergency department visits. More than 8,000 Medicaid beneficiaries from the District of Columbia were studied and evaluated based on four distinct social risk classes, the highest of which faced the greatest social adversities. Findings revealed the following about Class Four participants:
- They had the highest rates of unemployment, smoking, food insecurity, and housing instability.
- They had the highest need for primary care and ED utilization.
- They also had a 59 percent “primary care treatable” ED visit rate compared to participants who were employed and in a lower social risk class.
The more social barriers an individual faces, the greater the need for preventative care.
Payers and providers can save millions with SDoH interventions
Reading Hospital in Berks County, Pennsylvania, embarked on a mission to assess whether identifying and addressing the health-related social needs of local Medicare and Medicaid beneficiaries would impact total healthcare costs and inpatient and outpatient healthcare utilization.
Using the Healthify, powered by WellSky® platform, Reading Hospital’s community navigators helped patients understand, navigate, and access community social services. In one year, they referred patients to local services for food, housing, transportation, and other social needs, which resulted in a 15 percent decline in unnecessary emergency department visits for Medicare and Medicaid patients. This led to a cost savings of nearly one million dollars.
When payers and providers connect individuals to the resources they need, help them establish a primary care provider, and educate them on the purpose of emergency care, this not only saves money, but results in better care delivery and ultimately better health outcomes.
At Healthify, powered by WellSky®, we’re working with payers, providers, and community organizations to improve health outcomes and achieve ROI by delivering end-to-end SDoH solutions.
You can learn more about our work and how we provide value to payers and providers by reading our Reading Hospital case study here.