Guidance on ED use cuts down on nonemergency care

Health plans and employers often try to discourage patients from making unneeded trips to the emergency department by setting a relatively high co-payment for such visits.

But that practice might be unnecessary, according to an analysis by HealthCore, the clinical outcomes research subsidiary of WellPoint. Its research found that giving a patient information about what’s a true emergency and directions to the nearest ED alternative kept a significant portion of patients out of the emergency department — without the threat of a steep co-pay.

Members who were part of the company’s ED intervention program and were seeking emergency care received a short message about emergency care, along with Google Maps that showed the nearest ED alternative. The message said, in part: “Urgent care centers and walk-in clinics are a good choice when you need medical care quickly but can’t see your regular doctor. & Urgent care centers and walk-in clinics are often open nights and weekends and cost much less than an ER visit.”

The company’s analysis found a 17% drop in ED visits for nonemergency conditions in six months for the 32,000 WellPoint members in Connecticut who were part of the program.

The findings were comparable to what WellPoint saw from an earlier effort to cut emergency admissions for members in Virginia. The initiative included the same education about emergency care and directions to alternatives, but also had a higher ED co-pay as a penalty.

High co-pays can have unintended results, such as making it difficult for low-income patients to get care. They do little to discourage unnecessary visits by more affluent patients, said Jesse Pines, MD, a spokesman for the American College of Emergency Physicians.

“It could adversely affect people who have less money and the least access to other services,” said Dr. Pines, director of the Center for Health Care Quality and an associate professor of emergency medicine and health policy at the George Washington University School of Public Health and Health Services in Washington.

For years, WellPoint and other insurers have tried to reduce what they see as unnecessary or avoidable trips to emergency departments. They have been ramping up investments in research and interventions meant to curb ED use.

For example, in September 2011, Aetna purchased the developer of a mobile application called iTriage. The app allows members to check symptoms to gauge what’s a real emergency, then find directions to a doctor’s office, hospital, urgent care center or retail clinic.

A study by the RAND Corp. published in 2010 estimated that 17% of patients seeking care in the emergency department could be treated at an urgent care center or retail clinic.

Insurers cite higher ED costs and overcrowding as reasons to encourage patients to find an alternative, less costly place for nonemergencies. For example, WellPoint pays $610 on average to treat strep throat in an ED in Connecticut, but it pays $38 at a retail clinic or $78 on average at a walk-in urgent care clinic, said company spokeswoman Lori McLaughlin.

Dr. Pines acknowledged the difference in the cost to the insurer. But he said it’s important to consider the costs, monetary and otherwise, to the patient and surrounding community when he or she visits an ED instead of a retail clinic.

He said the patient saves time away from work by visiting the ED, and the incremental cost to the community is marginal. That’s because the ED will be open whether or not a patient with strep throat is treated alongside patients who have broken limbs or gunshot wounds.

“If we reduce overall emergency department visits for low acuity conditions, I don’t see that as a bad thing,” Dr. Pines said. “I just don’t think it’s going to save a lot of money.”