Let’s Fix the Path to the ER

It’s happened to you, or someone you know -- a trip to the emergency room (ER). It could’ve been for a broken arm, or a life-threatening stroke or heart attack.

The ER staff probably did a great job. But was going to the emergency room the right location to receive the care? While you may have had a serious issue, people walk into the ER every day with upset stomachs and coughs.

Impacting People and Costs

As consumers, it’s never easy going through the ER system. Waiting rooms are often overcrowded, and according to the CDC, “reported average emergency department wait times (about 30 minutes) and treatment times (about 90 minutes)… add up to roughly two hours in the ER.” There is also a lack of transparency that concerns consumers.

The function of the ER is to manage life-threatening conditions, not to diagnose a non-acute ailment. Often, a complex workup with blood tests and imaging studies is performed to rule out a life-threatening condition and will require an outpatient follow-up with a specialist for a more complete workup. However, information on tests performed is rarely passed along to the patient’s primary care physician because the ER doctor has moved on to the next crisis (it’s what they do). This negatively impacts the patient.  

It’s a critical issue, because ER costs are rising. The latest Health Care Cost Institute report found that the “price of an ER visit jumped 10.5 percent to an average of $1,863 in 2015.”

While overall ER utilization was slightly less, based on one analysis, costs still increased by double digits in terms of percentage. At Humana, we’ve seen firsthand the challenges of today’s ER utilization and costs among our members.

Yet in many cases, these members are going to the ER not for life-threatening emergencies, but for management of a chronic condition -- for example, a prescription refill since they were unable to see their primary care physician during normal business hours.

Since seven of 10 Americans live with chronic conditions -- such as heart disease, Type 2 diabetes, obesity and arthritis -- the health care system needs to make sure the chronic condition epidemic is better-managed, or the ER system will be hampered in its ability to treat life-threatening matters.

Hospitals and health plans spend way too many resources debating what was classified as an admission and whether it should have been classified as an observation. Given the fact that 71 percent of ER visits could have been avoided, more emphasis must be placed on and resources devoted to alternatives that can prevent ERs from being overloaded.

Solutions to the Problem

If we want to fix the ER decision path, and rising costs, here are five initiatives that could help.

1.    Enable the primary care physician (PCP) to be more proactive, not reactive. In a population-health world, the PCP is the quarterback, coordinating patient care among the specialists. Consider a PCP who has 100 patients with a diagnosis of congestive heart failure in her care and who knows that many of her patients will overindulge over the upcoming holiday season. Why can’t she work with a health plan to help educate them on tips to eating healthy over the holidays? High salt intake is directly linked to fluid retention, which can lead to a CHF exacerbation. If the PCP is not managing the patient and given an opportunity to intervene, her patient could wind up in the ER. Patients always need access to their PCP in a timely manner.

2.    Secure timely specialist care when necessary. Upon PCP direction, getting appropriate specialty care can help alleviate ER usage and drive down costs. At Humana, we’ve found that when you get a member to see a specialist, it greatly reduces the chance that the member will wind up in the ER. Yet, it’s not as easy as it sounds. If someone is referred to a specialist and it takes 25 days to see that specialist, a complication might occur and the person would have no choice but to go to the ER. It’s imperative that health plans and specialists find better ways to get at-risk patients in faster.

3.    Improve medication adherence. According to research cited in Health Affairs, “approximately 4.3 billion prescriptions were written in the United States in 2014, but fewer than half of patients take medications as prescribed.” Research has shown that poor medication adherence can lead to increased ER utilization. Greater resources must be invested in helping people stay current on their medications, which can also address overmedication and adverse drug reactions

4.    Educate on ER vs. urgent care. It’s the age-old argument, and there’s no shortage of information available online, yet urgent care can be an option to help drive down utilization. A recent study in the Annals of Emergency Medicine found that “consumers are just as likely to go to the emergency department for low-level problems like bronchitis or urinary tract infections.” Health plans and others must continue to help educate consumers about the rationale for each.

5.    Let’s utilize technology. According to a Harvard Business Review story, “40% of hospital beds lie empty, their enormous fixed costs weighing heavily on the system.” While some argue for expanding acute care options, high utilization and lower costs can be better achieved through expanding access to the PCP in communities, which will help access. If we want to keep the ER open for serving true emergencies, we need to invest more in access points and ease of care. We need to encourage telehealth solutions and predictive analytics to target patients when they are at risk for decompensating.

Let me be clear. Our country has some of the finest, if not the best, ER physicians, nurses, and other clinical practitioners in the world. These physicians and nurses save lives every day. If we want to help them focus on serving people who have actual emergencies, the health care system needs to recognize that the path to the ER is broken and must be addressed.

It certainly won’t be easy. It’s ingrained in us by the automated message you receive when you call your doctor’s office after hours: “If this is a life-threatening emergency, please go to the emergency room.” As I mentioned earlier, 71 percent of ER visits are unnecessary. We can all do better – hospitals, health plans, and consumers – to check our options before we go.

There will always be breaks in the system – people going to the ER for a cough when a call to their primary care physician or urgent care may have been appropriate – but these costs are escalating and must be addressed.

There are too many paths leading to the emergency room. That’s stressing our larger health care system, and the time has come to do something about it.