America’s hospital emergency rooms are overcrowded with patients who may be better served in doctors’ offices or other clinic settings, according to a national study of insured emergency patients conducted by the Blue Cross and Blue Shield Foundation on Health Care
and the Schneider Institute for Health Policy at Brandeis University
The study, which examined PPO claims data over a three-year period from 2.2 million Americans insured under a single large national account in all 50 states, found that patients with selected ambulatory care sensitive conditions (ACSC) had significantly higher emergency department (ED) utilization – as much as 2 to 3 times higher -- including repeat visits and consequent higher overall healthcare costs. ACSCs were defined in the study as high volume conditions such as congestive heart failure, pneumonia, chronic obstructive pulmonary disease, asthma, hypertension and diabetes that have a demonstrated relationship to avoidable hospitalizations.
The study is the first of its kind to look at claims data for ED services. Previous studies have been based on hospital surveys that focused on such factors as the availability of physicians and nurses and the number of beds. “Because the privately insured account for more than half of the recent growth in emergency department utilization, there may be ways to address the problem upstream and not just focus on the supply side,” said Blue Cross and Blue Shield Association Chief Medical Officer Allan Korn, M.D. “This new study provides a balance in understanding supply and demand issues and also sheds an important light on potential areas where insurers and physicians can work together to provide better patient care in more appropriate and less costly settings.”
Other key findings of the study:
Regular physician contact is a factor in reducing ED utilization and costs. For example, more than half (52 percent) of hypertension patients using the ED had zero physician visits in the prior year.
One in five ED visits were for selected low acuity conditions (see Appendix
A, Table 2 for the list of low acuity conditions) such as sore throat and minor rashes. These are visits that can generally be safely treated in a physician’s office.
The single most important contributor to the overall ED cost per member is the increasing proportion of members (10 percent) using the ED at least once.
Congestive heart failure and pneumonia patients using ED services in the prior year had higher hospitalization rates and overall costs in the current year. ED use in these patients may be a flag for more extensive care management by health plans and physicians.
”We know that regular physician contact is a factor in reducing emergency department utilization,” said Korn. “When we analyze health plan emergency claims data, we should be able to flag those patients who have had few or no physician visits and help them get care for their conditions in a doctor’s office, rather than in a crowded emergency room.”
Blue Cross and Blue Shield Plans are working with physicians to increase patient education and expand physician accessibility in order to keep patients with low-acuity from resorting to emergency room care. “More regular contact between doctors and patients naturally leads to better, more appropriate care,” Korn said. “It can also alleviate the overcrowding of emergency rooms, and it is highly likely that there will be demonstrated cost savings to the patient, as well as to the healthcare system.”
“It is incumbent upon all healthcare stakeholders to have a role in developing policies and processes to better manage emergency department services,” he said.
A more extensive study of emergency department utilization is underway in California and includes HMO patients, who have a clearly designated physician or “medical home” as compared to PPO patients. Blue Cross of California, Blue Shield of California and the Blue Shield of California Foundation are collaborating on the study with the Schneider Institute for Health Policy at Brandeis University and the Blue Cross and Blue Shield Foundation on Health Care. Study results are expected in early 2005.