FierceHealthcare source article | Comments courtesy of Matt Zavadsky
Interesting brief from UnitedHealthcare – this is likely a driver for payers discussing in earnest alternate payment models for EMS, models that add value to the payer through appropriate navigation of beneficiaries who access 911 for their healthcare needs.
UnitedHealth: Healthcare could save $32B annually by diverting avoidable ED visits
by Jacqueline Renfrow
Jul 22, 2019
UnitedHealth Group says 27 million annual trips to the ED are unnecessary.
One of the biggest contributors to the rising costs of healthcare is avoidable visits to hospital emergency departments (EDs). In fact, up to two-thirds of the annual 27 million ED visits by privately insured people in the U.S. are avoidable, according to a new brief (PDF) from UnitedHealth Group.
The average costs of treating these conditions in an ED is $2,032, which is 12 times higher than the $167 it would cost in a physician’s office. The cost is even 10 times higher than visiting urgent care—on average $193.
Overall, UnitedHealth Group says the healthcare system could save $32 billion a year by diverting these ED visits to primary care or urgent care.
UnitedHealth Group defines an “avoidable trip” as one that could be treated in a primary care setting. In other words: not an actual emergency. Some of the conditions seen in EDs that could be handled by a primary care physician include bronchitis, cough, dizziness, flu, headache, low back pain, nausea, sore throat, strep throat and upper respiratory infection.
“The high number of avoidable hospital ED visits is neither a surprise nor a new problem,” L.D. Platt, UnitedHealth Group vice president of external affairs communications told FierceHealthcare in an email. “Uneven access to timely, consumer-friendly and convenient primary care options is a longstanding problem, and there is a need to bolster and expand primary care capacity through urgent care centers, physician offices and nurse practitioners.”
Platt notes, however, that until there are better options, consumers will continue to visit EDs for primary-care-treatable conditions.
What are the main contributors that make ED visits so much more expensive?
First, hospital facility fees, which cost an average of $1,069 per patient visit. And second, lab, pathology and radiology services cost around $335 per visit at a hospital and $31 at a doctor’s office.
“Increasing primary care capacity and making primary care options more available and accessible to consumers beyond normal business hours will help consumers avoid unnecessary and costly visits to hospital EDs,” Platt said.
Of course, taking direct action to curb avoidable visits under control has proved to be a trickier proposition as insurers' attempts to target non-emergency use of the ED have faced heavy criticism and lawsuits.For instance, Anthem’s Blue Cross Blue Shield of Georgia was sued last year after instituting a policy to retrospectively deny payments for emergency department encounters it deemed “non-emergent." UnitedHealth also announced it was adopting a new policy for emergency services last year, saying that if it decided a coding— denoting intensity of emergency services provided in an ED—was not justified, they could downcode provider reimbursement or reject it completely. It has faced some pushback from some providers over its claims denial policies.