reducing unnecessary emergency department visits

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Policies That Limit Emergency Department Visits and Reimbursements Undermine the Emergency Care System : Instead, Let’s Optimize It

• 1 Department of Emergency Medicine, University of California, San Francisco
• 2 Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
• Original Investigation Insurance Coverage Denials for ED Visits With Nonemergent Diagnoses Shih-Chuan Chou, MD, MPH; Suhas Gondi, BA; Olesya Baker, PhD; Arjun K. Venkatesh, MD, MBA, MHS; Jeremiah D. Schuur, MD, MHS JAMA Network Open

Emergency department (ED) visit rates in the United States have been rising over the past 2 decades, outpacing population growth. 1 These visits are portrayed in the lay press as unnecessary visits that must be reduced or avoided. Yet a growing body of evidence indicates that most ED visits are medically necessary and that EDs serve as a critical source of care for high-risk patients, including those with comorbid mental health diagnoses, substance use disorders, and poor social determinants of health. Insurance companies and other payers have a years-long history of attempting to dissuade individuals from using the ED by refusing to pay for their visits—after the visit occurs—if it is categorized as nonemergent. In 2012, the Washington State Health Care Authority attempted to pass legislation stating they would only pay for ED visits for Medicaid patients that they deemed to be medically necessary. More recently, the health insurer Anthem implemented a similar policy, evaluated by Chou et al. 2 Their study examines this policy, which denies payments for ED visits based on a patient’s discharge diagnosis. At first glance, this idea makes sense: no one wants to pay for an ailment that could have been treated in a less expensive setting. However, policies that deny payments based on discharge diagnosis put vulnerable patients at risk and have significant flaws.

First, there is no way to make an accurate determination of medical necessity for emergency care in advance. In a previous study, 3 my colleagues and I examined whether a patient’s symptoms at presentation to the ED could be labeled reliably as a nonemergency based on the discharge diagnosis—the diagnosis that Anthem is currently using to determine medical necessity. We found it was impossible. We restricted our analysis to include only discharge diagnoses that were categorized as nonemergent or primary care–treatable. 3 We linked this group of nonemergency diagnoses back to their corresponding chief concerns from when the patient had arrived at the ED. When we examined the universe of outcomes related to these chief concerns, we found 12.5% of patients with these presenting concerns required admission to the hospital (including the intensive care unit), and 3.4% went directly to the operating room. As emergency clinicians, we wait until after a workup to assign a discharge diagnosis: this workup is based on a detailed history and often involves blood work, imaging, and multiple hours of observation. That the same presenting symptoms that resulted in some patients going to the intensive care unit and others being denied coverage because the visit was considered unnecessary makes clear the impossibility of patients judging medical necessity.

While few would argue that some proportion of patients who visit the ED could in theory be cared for in other settings, several recent studies have shown that most patients who seek care in the ED have urgent concerns. 4 Their decision to come to the ED is rational. It is clear (even by Anthem’s own estimates) that the vast majority of ED visits are not unnecessary. Other studies have shown that individuals feel ED-based care is of higher quality and that a wider variety of services are more accessible. 5 The nation’s primary care system is overstretched: outside of a few contained systems (eg, Kaiser) most primary care systems are unable to meet patients’ need for timely care. And an additional force is at work that deserves more attention: outpatient clinicians are referring their patients into EDs at high rates. Our recent study 6 found that about 25% of US adults with 1 or more ED visit in the previous year had been referred to the ED by an outpatient clinician. Primary care clinicians recognize that the ED can facilitate advanced evaluations and observation to help determine the need for hospitalization—functions that often cannot occur in busy outpatient clinics.

Perhaps it is not surprising, then, that Anthem is coming to terms with the fact that their policy to deny payment is not working. The insurance company is learning what we already know from peer-reviewed research: most patients in the ED are there for good reasons, and it is hard to prove otherwise. And despite a proliferation of programs aimed at reducing ED visits using mechanisms other than denying payment, lowering ED use has proven an elusive goal. 7 To make a dent in ED use, our health and social care systems must improve access to primary care, behavioral health, and community-based resources. This type of investment will take a large amount of political will over many years. The United States spends more than any other Organisation for Economic Co-operation and Development nation on health care. However, it ranks near the bottom on the percentage of gross domestic product spent on social programs such as employment and housing—services that have been shown to directly affect health outcomes. 8 Until significant and sustained investment in community-based health and social services becomes a priority for our nation, EDs will remain the de facto safety net.

Pushing people out of our nation’s EDs is myopic. Policies like those put forth by Anthem place an unfair burden on patients. Discouraging people from seeking needed care will lead to higher downstream costs for untreated illness and defeat the insurer’s (misguided) attempt to lower health care expenditures. While ED visits in and of themselves account for a relatively small share of overall health care spending (2%-6% depending on the study 9 ), inpatient care is one of the leading drivers of health care costs nationwide. A recent RAND report 10 found that ED clinicians are now decision makers for more than 50% of all admissions to hospitals in the United States. Any ability to help reduce hospital admissions sits squarely on the shoulders of ED clinicians. We are already experts in attempting to “turn patients around” so that they do not require admission to the hospital: of 136.9 million ED visits in 2015, only 9% were admitted to the hospital. Yet there are other untapped areas that can lead to lower downstream costs and improved outcomes for our patients. Testing for HIV, screening and initiation of medication-assisted treatment for substance use disorders, information technology platforms that facilitate real-time care coordination for high-risk patients, and increased focus on addressing social determinants of health, including homelessness, are increasingly seen as fundamental to emergency care. Rather than viewing ED visits as adverse outcomes that must be reduced, we can try to optimize these visits and the myriad functions EDs have the potential to provide. Emergency departments have become an invaluable health and social service hub for patients and clinicians alike; the next step is to fund, implement, and research the impact of cutting-edge emergency services that can provide value for our patients and our health care system. Our federal mandate is to provide care for all comers. We have 136.9 million chances to positively affect patients every year. Let us do it right.

Published: October 19, 2018. doi:10.1001/jamanetworkopen.2018.3728

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2018 Raven MC. JAMA Network Open .

Corresponding Author: Maria C. Raven, MD, MPH, MSc, Department of Emergency Medicine, University of California, San Francisco, School of Medicine, 505 Parnassus Ave, San Francisco, CA 94143-0209 ( [email protected] ).

Conflict of Interest Disclosures: Dr Raven is an elected member of the California Chapter of the American College of Emergency Physicians Board of Directors and a volunteer member of the clinical advisory board for Collective Medical, creator of an information technology platform that allows emergency providers to view visits for frequent emergency department users outside of their own facility and to develop care guidelines to help coordinate care.

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Raven MC. Policies That Limit Emergency Department Visits and Reimbursements Undermine the Emergency Care System : Instead, Let’s Optimize It . JAMA Netw Open. 2018;1(6):e183728. doi:10.1001/jamanetworkopen.2018.3728

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Case Study: Preventing Unnecessary ER Visits With Real-Time Tracking

Dr. Gina Johnson of NEVHC with young patient, pre-COVID

Asthma is a complex, chronic, and costly disease that disproportionately impacts vulnerable children and communities of color. That’s not news to Northeast Valley Health Corporation , based in Los Angeles County, which serves low-income, mostly Latino patients in 15 health centers across the San Fernando and Santa Clarita Valleys.

The healthcare powerhouse — one of the nation’s largest community health centers — prides itself on the way its asthma care coordinators, educators, and providers work closely with their pediatric patients and their families to ensure that every child with asthma or asthma-like symptoms receives a health care treatment plan tailored to his or her needs. But despite the NEVHC’s care teams’ best efforts, all too frequently asthma patients land in the emergency department for non-emergency care.

The debilitating respiratory condition — which can flare up and trigger acute, worrisome breathing difficulties in young patients — can be tricky to manage and cause children and their concerned parents tremendous stress, discomfort, and pain.

Rosa Garcia, NEVHC asthma care coodinator, with patient (pre-COVID)

Asthma symptoms can spike at any time — including afterhours for medical clinics — often resulting in emergency department (ED) visits. “We teach our patients and their families self-management strategies to control their asthma and keep them out of the emergency room,” explains Rosa Garcia, lead asthma care coordinator at NEVHC. “We also inform our families that they can get advice from the provider on call whenever the health center is closed. However, some of our patients continue to use the emergency room for non-emergency care. After our follow-up phone calls, they realize that there are safe ways to control symptoms and avoid ED visits.”

These ED visits can be traumatic for patients and their families and cause preventable medical costs. Asthma is an expensive illness, totaling more than $50 billion a year in medical costs. The lung disorder accounts for 1.7 million ED visits a year, according to the Asthma and Allergy Foundation of America , making it one of the top 20 reasons for emergency room visits. On average, an asthma-related trip to the ED costs $1,502.

So keeping non-emergency asthma visits out of the ED is a genuine safety net clinic concern. It’s also easy to understand how patients end up there. NEVHC patients, like many others receiving Medi-Cal, may have had to deal with work, childcare, or transportation constraints that impacted their ability to make in-person primary care appointments for their children in pre-pandemic days, notes Debra Rosen, NEVHC’s director of quality and health education.

“For many of these patients, the ED was a one-stop shop where patients had 24/7 access to care without any financial deterrents or co-pays,” explains Rosen. That’s not the only reason so many pediatric asthma patients showed up in emergency departments before COVID-19 hit. “Our patients may not fully understand when to seek emergency care and the important benefits of continuity visits with their primary care provider. They also may not take advantage of after-hours telephone access to a NEVHC provider,” adds Rosen.

It’s a complicated problem. And NEVHC asthma care teams and their primary care physicians (PCPs) had long been in the dark about whether their asthma patients were presenting in emergency departments for true emergency treatment or simply routine care. Absent that information, there was understandable concern about a troubling lack of continuity of care, particularly with patients receiving non-emergency care at an emergency department visit.

Project Profile

The Northeast Valley Health Corporation (NEVHC) is a Federally Qualified Health Center located in Los Angeles County and one of the nation’s largest community health centers. NEVHC serves low-income, predominantly Latino populations as well as special demographics across the San Fernando and Santa Clarita Valleys. Special populations include vulnerable groups such as school students, the unhoused, HIV+ residents, and participants in the Women, Infant, and Children (WIC) program. In 2018, NEVHC served almost 76,000 unique patients with more than 326,000 visits through its 15 health centers.

Collective action to the rescue

How to address this intractable issue? Here’s what NEVHC staff did know: They had a continuity of care problem. They often found out about patient emergency department visits in an ad hoc fashion—frequently well after the fact. Parents or guardians might call to schedule a follow-up visit, or report the ED visit at a subsequent appointment. Sometimes the asthma team received what’s known as a Continuity of Care Document (CCD), which is sent to primary care clinics through the Health Information Exchange (HIE) directly to a patient’s chart with or without notification.

This inconsistent tracking “system”—from a variety of sources of mixed reliability—meant that care coordinators were often not able to provide timely, appropriate, and complete follow-up care to help a patient manage asthma and attempt to avoid preventable future emergency room use. From a safety net clinic perspective, it was frustrating, worrisome, and a poor use of limited resources.

Surely a technology solution could help address this matter?

Bingo. NEVHC learned about a healthcare information sharing network Collective Medical , which provides a comprehensive way to receive electronic notifications when an assigned managed care member presents in an emergency department or hospital. The Utah-based patient data information platform is designed to help care teams collaborate to support the most vulnerable patients, those whose needs can’t be met in any single care setting. It offers services designed to address readmissions, opioid addiction, behavioral health, workplace safety, and other concerns. Its ED utilization program is constructed to reduce unnecessary ED visits by addressing their cause.

#Asthma is serious! Across the U.S., asthma affects over 6 million kids, and it can interfere with their health & development. NEVHC is here to care for your child's asthma. Schedule an appointment today. Call (818) 270-9777 or 661) 705-2040, or visit: https://t.co/l67Albma5r pic.twitter.com/BQyS2UEiuT — Northeast Valley Health Corporation (@NEVHC) June 16, 2020

NEVHC was introduced to Collective Medical through Health Care LA – IPA , which provided funding for the project. Health Care LA – IPA is a not-for-profit network of Federally Qualified Health Centers (FQHC) and community health centers serving vulnerable patient communities in Los Angeles County since 1991. It provides expertise and resources to its more than 40 health center members.

NEVHC is also a member of CCI’s Technology Hub . CCI, with support from the California Health Care Foundation , partners with safety net clinics such as NEVHC to vet, pilot, evaluate, and integrate innovative digital health solutions designed to benefit underserved communities. For instance, NEVHC has worked with CCI in the recent past on piloting a digital platform for respiratory health management for asthma patients , and introduced a free, online social services referral platform for patients, among other tech innovations. NEVHC was also one of seven clinics chosen to be part of CCI’s ROOTS program which looked at social determinants of health; the health center focused on a digital tool for screening patients for food insecurity .

NEVHC staff worked directly with Collective Medical to identify specific criteria for asthma or asthma-like symptoms documented as the chief complaint in an emergency room visit and set up a process to generate electronic notifications to designated staff via email—in this case a health educator and the director of quality and health education—when a patient presented in the ER. Rosen wanted to be in the loop to get a real time sense of the volume of notifications, she says, and to oversee the project.

As part of NEVHC’s workflow, the health educator responded to each alert, reviewed the patient’s record in NextGen , the health center’s electronic health records (EHR), and, based on previously established guidelines, sent an alert through the system’s EHR to either the provider or asthma care coordinator, who followed up with the patient as needed.

Reports from these alerts, which were manually generated, included data such as the total number of pediatric notifications, number of assigned members who had never been seen at NEVHC, number of repeat patients, number of patients with or without an asthma diagnosis, and the number of provider test actions created. Rosen says the system generated a lot more alerts than expected, and many of them were for patients without an asthma diagnosis.

During this pilot program, which ran between December 18, 2018 and August 8, 2019, NEVHC received 1,046 emergency department notifications. Of those, 172 were pediatric patients with an asthma diagnosis and 661 were pediatric patients who did not have a diagnosis for the disease. The number of repeat pediatric patients in the mix totaled 106, and 32 of the patients had never been seen at NEVHC. The alerts generated 771 provider test actions.

The data is reviewed and analyzed each month by NEVHC’s asthma quality improvement committee. Initially, Rosen recalls, there was a lot of discussion about the number of alerts generated and the subsequent number of provider test actions. There was a lot of variability in the number of alerts—between flu season and non-flu season, for example.

During the height of the 2018-2019 flu season provider alerts jumped from a baseline of one to three alerts a day to around 13 a day, which proved taxing for staff and providers. While increasing their workload, it’s also part of their job description to improve patients’ ability to manage their asthma symptoms, says Rosen. That said, since COVID-19, those alert numbers have dropped dramatically. “That tells me two things,” says Rosen: “There’s a lot of inappropriate use of the ED — and, for those patients who may really need to use it, they may be too scared to go.”

Expanding Collective Medical to other cohorts

Across the board, NEVHC viewed the digital tracking system as a valuable addition to their online arsenal.

Jasmine Uribe, NEVHC asthma coordinator

“Collective Medical is a useful tool to gather real-time information on patients who are being seen in the emergency department,” says Jasmine Uribe, a health educator and asthma coordinator at NEVHC. “We learn about patients who have never been seen by their assigned PCP or who need to schedule a follow-up visit with their PCP. And we are able to provide education, support, and connect these patients back to primary care and hopefully reduce ED visits in the future.”

The NEVHC team is keen to find ways to prevent unnecessary frequent flyers to the ED.  “Receiving notifications in real time that one of our assigned patients is in the Emergency Department or has been admitted to the hospital can potentially reduce ED utilization, reduce readmissions, support transitions in care, and improve patient outcomes,” says Rosen.

Physicians see the merit in Collective Medical too. “The utility of the alerts were that we could assess the patients and determine the appropriate timing for follow up visits,” says Gina Johnson, medical director of pediatrics at NEVHC. “We have also been able to make full use of our asthma educators’ case management and health education skills for prevention of future inappropriate ED visits and indications for visits with their primary care providers.”

There were some unexpected benefits of the program, notes Rosen. “Occasionally we found a more accurate telephone number provided in the ED, which helps support follow-up,” she says. “We were also surprised by how often our patients frequent the ED. And we found patients assigned to NEVHC but who had never been seen at our clinics. This provides us with an excellent opportunity to try to engage the patient and establish care with a primary care provider.”

And, of course, there are some additional costs to adding something new to staff workloads. “It also adds work without direct reimbursement. Personnel resources are needed to respond to notifications, staff must be identified to follow-up on the notifications, and providers must evaluate next steps for the patients,” Rosen explains.

The scope of the project did not include funding to evaluate the program, which is unfortunate, says Rosen, because it makes it challenging to get a handle on how useful the tool actually is at keeping patients out of the ED unnecessarily, among other measures. In an ideal world, she adds, the pilot would have been conducted alongside another health center, for comparison purposes.

That said, the Collective Medical platform offers FQHCs “enormous opportunities, says Rosen.

Lessons Learned

Identify the right staff. For the Collective Medical pilot to run smoothly, it was important to make sure the appropriate team members were designated to receive alerts—somebody who could add to their current work load—and be able to provide follow-up.

Consider clinical priorities. Which patients might most benefit from this kind of information sharing system? Start there to pilot this program and track whether or not it leads to improved clinical outcomes.

Create an evaluation plan. The goal here is to optimize patient outcomes and reduce inappropriate ED use, so make sure you include an effective way to monitor if these goals are actually being met as part of the pilot. While a control group may not be clinically defensible in these kinds of situations, a comparison study may help tease out trends in data, such as whether the pilot decreased emergency department use.

The intervention works from a functional end, in that NEVHC is now in the loop when its patients land in the ED. But the clinic would welcome additional resources to evaluate the effectiveness of the intervention. Has there been a decrease in emergency department visits for pediatric patients with asthma—as well as pediatric patients without an asthma diagnosis?

There are, of course, many ways to follow up with these patients and support their care. For instance, with pediatric asthma patients who are high frequent users of the emergency department—for the purposes of this project that was considered 12 ED visits in a year—care teams identify resources and interventions that may help resolve these acute incidents without the need for an ED visit in the future.

NEVHC saw enough value in the new approach to roll out the program to other patient populations. The center is currently using Collective Medical for its diabetes patients who land in the ED, as well as patients who frequent the emergency department and are eligible for Health Homes , a Medicaid program for patients with multiple, chronic conditions. The program is designed so providers can integrate and coordinate all primary, acute, behavioral health, and long term services and supports a “whole person” approach to health care.

NEVHC also plans to prioritize higher risk adult Medi-Cal managed care members who have never been seen in the clinic setting but are regular emergency department visitors or frequently hospitalized for outreach efforts.

“The solution works and this technology provides enormous potential to decrease ED utilization, reduce hospital readmissions, and improve outcomes for our patients,” says Rosen. “The challenge is to align incentives to support the technology and the resources needed. As we strategize about how to expand this work, we have identified many opportunities to reach out to other populations—such as patients with diabetes, those who are eligible for Health Homes, and assigned members who have never been seen at NEVHC. This will help us connect these patients to primary care.”

“We think they will be more receptive to routine care following an ED visit — oftentimes patients don’t feel they need primary care services or that they have health issues,” Rosen concludes. “They’re a bit more inclined to come and see a provider and establish care when we follow up after an alert. It’s a great way to reach patients who could benefit from our services.”

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Reduce emergency department visits for nonfatal unintentional injuries — IVP‑04

Status: target met or exceeded.

Most Recent Data: 6,477.2 emergency department visits for nonfatal unintentional injuries per 100,000 population (2021)  *

Target: 7,097.8 per 100,000 1  *

Desired Direction: Decrease desired

Baseline: 8,620.6 emergency department visits for nonfatal unintentional injuries per 100,000 population occurred in 2017  *

*  Age adjusted to the year 2000 standard population.

Reduce emergency department visits for nonfatal unintentional injuries

Data Sources:  National Electronic Injury Surveillance System - All Injury Program (NEISS-AIP), CDC/NCIPC and CPSC ; Bridged-race Population Estimates, CDC/NCHS and Census

Learn more about data measurement for this objective

Every year in the United States, millions of people go to the emergency department for unintentional injuries. Strategies to prevent specific types of nonfatal unintentional injuries — like falls, traumatic brain injuries, and motor vehicle crashes — can reduce emergency department visits.

Topics:  Injury Prevention , Hospital and Emergency Services

Workgroup:  Injury and Violence Prevention Workgroup

Other objectives you may be interested in

• Reduce emergency department visits for nonfatal injuries — IVP‑02
• Reduce deaths from motor vehicle crashes — IVP‑06
• Reduce fall-related deaths among older adults — IVP‑08
• Reduce fatal injuries — IVP‑01
• Reduce fatal traumatic brain injuries — IVP‑05

1. Target has been revised. See Data Methodology and Measurement for more information.

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