March 28, 2019
From the patient perspective, going to the emergency room may seem like an inexpensive, fast way to get medical care.
Then again, maybe not. It certainly isn’t inexpensive for the health plan or the ER. And in today’s era of high deductibles, it can be unexpectedly costly for patients as well.
The fact is that up to $18 billion is wasted annually because of inappropriate ER visits, and misuse of the emergency room as a primary or urgent care provider is a major driver of unnecessary plan costs.
Historically, a combination of written and telephonic communication has been used to educate members on urgent care options and when to call the doctor before going to the ER. More recently, telemedicine solutions have emerged as viable and convenient alternatives to the ER.
Strategies that are fine-tuned for specific demographics can promote smarter ER utilization while still ensuring the best health outcomes for members. Here’s a look at some of those specific groups and some educational tactics that we recommend based on age group.
Every day, 10,000 Baby Boomers (those born between 1946 and 1964) reach retirement age. Employees are staying in the workforce longer – the American Association on Aging reports that by 2020, 25.5 percent of the labor force will be 55 years old or older, compared with 19.5 percent in 2010.
A hospital survey by the U.S. Centers for Disease Control and Prevention (CDC) found that the 65-plus population made more than 20 million trips to an ER in 2013, up from 16.2 million in 2000. By 2030, projections show that 24% of ER visits will be made by seniors.
Aging increases the risk for cancer, stroke and heart disease; as a result, these workers make up the patient population that is most likely to develop a chronic and/or a complex illness.
This group is most likely to have health issues and is genuinely concerned about the potential for serious health consequences if they begin displaying symptoms, have a fall, or appear to be relapsing. These situations are the driver of their ER use. They did not come of age during a time when there were alternatives to the ER like urgent care or virtual visits. Instead they were taught from childhood that sudden medical emergencies at off hours require a visit to the ER. So, changing their understanding of the health services that are available to them today can be challenging.
Six specific strategies are most effective in reducing unnecessary ER utilization by seniors and Baby Boomers.
- Have a plan. Everyone with a chronic or critical illness should have a plan for what to do if health issues arise. For example: “If you experience Symptom X, call your primary care doctor. If you experience Symptom Y, go to the ER.” A care navigator or case manager should be assigned to patients with chronic or critical illnesses. They can act as the first line of support to reiterate this plan and ensure that patients access preventive care benefits so they can avoid health setbacks. The care manager can also educate patients on symptom self-management to avoid having to visit a healthcare provider altogether.
- Palliative care services should be covered and encouraged. This relatively new care approach – falling between hospice and ongoing care management – recognizes that some people have an illness from which they may never recover. Examples include Alzheimer’s, Parkinson’s, ALS, congestive heart failure and many cancers. A palliative care team provides a more intensive level of support and oversight for the patient as well as the family. With closer supervision, medical problems can be prevented or addressed before they worsen. Care managers should encourage patients to communicate their needs to their palliative care team in order to avoid an unnecessary ER visit for uncontrolled pain.
- Manage medications and care delivery of complicated procedures. This age group is more likely to be taking multiple medications that may cause complications, or they may require specialty prescription drugs or treatments that could theoretically be administered in the ER but would be more cost-effectively administered elsewhere. By providing these patients with the proper instructions and identifying alternative settings to access treatments, care managers can prevent medical emergencies and consequent ER visits. The care manager should also identify any barriers to getting prescriptions filled (for example, a lack of transportation) and encourage members to fill all of their prescriptions at the same pharmacy for ease of management. Obtaining the proper prescriptions is important in order to prevent health issues from escalating to emergent status.
- Urgent care center education. Proactively identifying the location of the nearest urgent care center to the member, explaining what the urgent care center can do, and making sure that the member has the phone number, address and directions to the urgent care center will make this relatively new health care setting familiar to the member.
- Introducing digital advice options when appropriate. Some members of this age group are highly proficient with technology; some are not. For those who are, smartphones and tablets can be used to access telemedicine solutions and consult medical professionals over video. Many telemedicine services also offer landline options for those who do not have a smart phone. These services are usually used to triage minor issues before they escalate and to obtain common prescriptions quickly, without having to wait at an urgent care center or ER. However, they cannot be used to fill pain medications.
Telemedicine can also be a resource for people with a chronic illness – such as severe asthma, diabetes or heart failure – who need their prescriptions filled but are unable to visit their regular doctor due to schedule restrictions or a lack of transportation.
- Ensuring that the individual has a primary care physician. A primary care physician (PCP) can guide patients towards care that is less costly and more effective than the ER. PCPs can administer wellness visits, routine check-ups and health screenings. They can also coordinate care and refer patients to in-network specialists for other health issues. To encourage patients to designate a PCP, it’s important to make sure that they are aware of this benefit. Providing a search tool that they can use to find a local PCP will encourage them to take advantage of this service. Some health plans also offer discounted co-pays to members who designate a PCP.
Gen X and Older Millennials
Gen X and older millennials (30 to 50 years-old) have seen multiple changes in the health system in their lifetimes and are more likely to be open to doing things differently. They are also likely to be working adults, facing the usual challenge of finding time to go to the doctor during the work day. This group also lives on their smartphones, especially women.
This demographic is the most likely cohort to be parents and responsible for managing the healthcare for their children. They are the anxious moms and dads trying to decide if little Emma should go to the ER at midnight with this cough and fever or wait till morning. Should the doctor be called? What does Google say?
Tactics to optimize ER utilization for this group include:
- Introduce and promote digital visits, especially where the doctor can actually see the patient and make a recommendation after viewing the individual. Whether little Emma is happy and playful, or lethargic and fretful, makes a difference in the recommendation for what to do about her fever. These personal digital connections, available 24/7, are convenient and reassuring for parents.
- Telemedicine services are also important services for immediate, convenient professional advice and triage.
- Digital resources should be accessible and mobile-compatible. The most effective online resources should include information on local urgent care centers, access to video consultations, and links to educational material. Members should have access to a search tool that allows them to search for local urgent care centers and PCPs who are in-network. To maximize engagement, online tools should also be user-friendly and pleasing to the eye. Lastly, employers and benefits administrators should continuously educate members on these resources during the onboarding process.
- Use tried and true print materials as well. “Old school” techniques work with this tech-savvy group, too. Provide urgent care center information that can be tacked to the refrigerator, a triage chart for the bulletin board, and screening and immunization reminders via “snail mail.”
The third demographic group is younger millennials, aged approximately 23 – 30. This group may be experiencing the insurance world for the first time. With their desire for instant gratification and their unfamiliarity with the system, it’s easy for the healthy millennial to see the ER as a substitute for primary care. Young adults may also be accustomed to avoiding healthcare and allowing their symptoms to worsen before they take the time and spend the money to see a doctor, a practice that can lead to ER visits.
For younger millennials, education is key.
- Have a primary care physician. Get the member to set up a PCP as quickly as possible. Inform them of the importance of preventive treatments and the low or no-cost options to obtain them. Once these members have established relationships with a PCP, they can consult their doctors first when experiencing a health issue.
- Educate about urgent care. Make sure they know about their closest urgent care center and what types of services can be accessed there.
- Stress the convenience of 24/7 access to telemedicine advice and digital visits, and how easy they are to use.
- Communicate the disadvantages of using the ER when it’s not appropriate – long waits, exposure to sick people, and potentially high co-pays and medical bills. It’s interesting that millennials are the group that reports the greatest dissatisfaction of all groups with the ER experience. It’s really not where they want to be and not where they want to be treated. They do expect fast gratification, a trait that might lead them to not seek care at all. Educating this population on options for care may be more time-consuming than for older members, but it’s essential.
If you’ve noticed a common theme in these scenarios, you are right: the main take-away is to be proactive. In an urgent health situation, people have trouble thinking logically and recalling their options. They need to have the roadmap already in their head, close at hand, or on their phones.
Being proactive is how HealthComp generates a 4.3-to-1 return on investment for our ER Solutions program. By analyzing our claims data, we can identify patients who have used an ER when another healthcare setting would have been more appropriate. Once identified, HealthComp reaches out to these members to educate them on less expensive alternatives to the ER. And, patients who are likely to have problems that might precipitate an ER visit are identified in advance so that they can be counseled and prepared for what to do if health issues arise and they need immediate help. Correct ER utilization starts early, when the member is new, and continues at regular intervals on an ongoing basis.
The role of the care manager for those with chronic illness is absolutely critical to ER utilization management. From early education on treatment options, ensuring that the patient has a primary care doctor and a care plan, and to heading off situations with symptom management and care coordination, the care manager is an end-to-end quarterback.
Consumer-friendly technology plays a big part in member engagement. Easy online access to information both educates and prompts repeat engagement for members. Offering an integrated portal that is easy-to-use draws members back to find providers, locate alternative care sites, select a primary care physician, and use services such as telemedicine.
Helping to direct members toward alternative solutions has led to significant cost savings and changes in behavior for HealthComp clients:
- 12% increase in use of the urgent care center
- 5% decrease in non-emergent ER visits
In summary, the goal of the ER Solutions program is threefold:
- Preplanning and education for the people most likely to need ER services.
- Identifying the appropriate alternative settings for care.
- Introduction and education on telemedicine resources and easy technological access to information, anytime and anywhere.
Developing the appropriate mix of strategies based on the needs and habits of specific demographic groups will have the greatest impact on behavior, while ensuring that the member always receives the safest option for healthcare.