Emergency room overuse – and what benefits professionals can do about it

The issue of emergency room overuse has been gaining national attention in recent years. It was elevated recently when UnitedHealthcare, among others, announced new policies to retroactively deny emergency room claims for vists deemed non-emergent. The move prompted backlash from provider groups that expressed concern that such measures would discourage people from seeking care, ultimately leding to UnitedHealthcare hitting pause on the policy.

Such efforts by health insurance companies are a response to a new trend that’s been emerging in recent years: People are no longer visiting ERs only when there’s a sudden, serious or life-threatening emergency. Increasingly, patients are turning to their local ERs for regular care.

What gives? And why is this an issue benefits brokers and managers need to be aware of?

Related: United Health: COVID-19 curbed consumers’ appetite for ER services

Call it a symptom of a broken health care system. While not a new phenomenon, emergency room (also known as emergency department) overuse is quickly becoming a hot-button issue for several reasons:

• It’s a strain on the emergency department staff and resources.
• It drives up costs for payers, which in turn can drive up costs for employers and their employees, as care provided by the emergency department is much more expensive than a comparable office visit
• It indicates that there are underlying issues elsewhere in the health care and health benefits. ecosystem that are pushing patients to the ER when other avenues may be more appropriate for their needs.

It’s a complicated, expensive issue that costs the U.S. health care system an estimated $32 billion annually, according to a UnitedHealth Group study. Yet, it’s a delicate problem to address, as no one wants to discourage patients from seeking medical care.

The underlying factors

As the system as a whole struggles with this issue, we must take a step back and understand which factors are driving insured patients to go to the ER rather than their primary physician or clinic. Here are a few:

• Rising out of pocket costs for individuals prompt many to take a “wait and see” approach when experiencing medical issues in an effort to avoid incurring a co-pay or a bill that would strain their finances. But when left untreated, even seemingly minor issues can escalate quickly, causing symptoms that become a medical emergency, or may cause individuals to believe that they are experiencing one. In many cases, the situation could have been addressed by a primary physician at a fraction of the cost.
• Gaps in coverage and confusing pricing and policies can leave individuals feeling hesitant to actually use their health plan for primary care due to the fear of having to make an upfront payment, such as a co-pay. In such situations, some individuals may turn to an emergency room for care, where in most cases they will be treated without being asked for an upfront payment. The unfortunate outcome is that such visits will end up costing them much more in the long run.
• A lack of affordable preventive and essential care is a particularly vexing issue, as we all know an ounce of prevention is worth a pound of cure. Routine visits not only help catch issues before they escalate into serious condition, they also help educate patients on best practices for managing their health and well-being, especially when it comes to managing chronic conditions and understanding their symptoms, including when to seek emergency care. In the long run, a serious condition or mismanaged chronic condition will cost everyone involved much more than a few preventative appointments and essential screenings.
• Little to no education about what warrants a visit to the ER and the available alternatives for care. Let’s face it, when someone is in pain or worried enough to go to the ER, they’re probably not in the right mindset to begin researching after-hours care at their regular clinic, nurse hotlines or urgent care options in their area.

While this is by no means an exhaustive list of causes, it does begin to illustrate the multiple factors that contribute to ER overuse, and why it has become such a complicated issue to untangle.

A better way forward

We know measures such as retroactive reviews of emergency room claims run the risk of discouraging people from seeking out care when emergency treatment may truly be needed. We have to find a better way to get ahead of the problem in the first place. Although it’s a complicated issue, there are tangible, immediate steps that health plans, brokers and benefits managers can take to proactively curb ER misuse.

The first step: Health benefits providers need to design better health plans, with more options that emphasize and encourage routine and preventative care, and cost-sharing models that result in lower out-of-pocket costs for everyday services. This will encourage appropriate care with the right medical professionals at the right time, instead of fostering this “emergency only” mentality that results in ER overuse. Easier said than done, of course, but newer, outside-the-box health plans are doing exactly that by upending the traditional plan design models.

While the idea of making a difference by improving the design of health plans from the ground up may sound audacious and impossible, it’s not. There is mounting evidence from our company and others showing that it is indeed possible to drastically restructure health benefits, motivating individuals to seek out preventative care, keep up with their prescriptions and essential appointments, and use alternatives to the ER when other option fit their needs.

The second step: Scrutinize current and future plan options closely for how much they encourage (or hinder) routine and preventative care. If brokers and benefits managers prioritize and discuss preventative care coverage when assessing plans that best fit a company’s needs ahead of open enrollment, they can be confident that the plans presented to the company’s workforce incentivize individuals and their families to seek out care early, in a setting that’s not an emergency room when not warranted.

The final step: Educating workers and their families on why routine and preventative care is so important, how their health plan covers the care they need, and the full array of medical care options that exist between a yearly physical and the ER. Health plans, brokers and employers can all work together to provide proactive information to individuals and encourage them to regularly interact with their primary physicians to seek solutions for their health needs and screen properly for unforeseen issues that may arise.

While scheduling and keeping routine appointments has always been an uphill battle for people, the COVID-19 pandemic made the situation even worse. According to a JAMA study, 41% of respondents reported forgoing medical care due to concerns around COVID-19 or financial concerns during the pandemic. Even as the threat of COVID-19 declines in many parts of the U.S., the return to routine care has been slow. Proactively reminding and encouraging individuals to get back to regular check-ups and screenings, and providing information on telehealth alternatives where appropriate, can go a long way in getting ahead of potential issues as soon as possible.

Lastly, as employees select new health plans for the upcoming year, we have an opportunity to highlight the many medical care options available to them well before considering a trip to the ER when it may not be warranted. Let’s be a part of efforts to encourage individuals to learn about and use after-hours care at their primary care clinic, nurse hotlines, urgent care clinics and telehealth options, when appropriate. Likewise, we can share life-saving information on a regular basis through communications with plan members – for example, a newsletter highlighting common signs of a stroke or heart attack – to help individuals discern when an ER visit may actually be warranted.

ER overuse is a complicated problem, but we have an opportunity, and responsibility as key players in health benefits, to affect change proactively – and ultimately help individuals access the right care, at the right time.

Marek Ciolko is the CEO of Gravie.