ER cost control. The opportunity from health reform

As I’ve reported several times, insured patients use the emergency room more than uninsured patients. A new review of the literature confirms what I’ve been saying and adds a couple new points. From MedPage Today (Most ED ‘Frequent Fliers’ Insured)

Most patients who visit the emergency department (ED) four or more times a year have health insurance and a primary care physician…

Women and blacks were disproportionately associated with frequent ED use, but the data showed that, in absolute numbers, the majority of frequent ED users — 60% — were white. The mean age was around 40.

LaCalle and Rabin noted that “many studies on frequent ED use have considered the influence of insurance status and have found this patient population to be predominantly covered.”

Much of that coverage, however, is provided through Medicare and Medicaid, and frequent ED users are more likely to be enrolled in those programs. “Among those patients who can be characterized as ‘occasional’ users, 36% are publicly insured,” the researchers found, “versus the 60% of frequent users who carry Medicare or Medicaid.”

One national survey cited by the researchers found that the odds ratio for patients with government insurance being frequent users was 2.1 (P<0.001).

The information on public insurance is interesting. Too bad the authors (or at least the MedPage folks who summarized the study) didn’t separate Medicaid and Medicare. I’d expect Medicare patients to use the ER and other services more because they are mostly older than 65. The Medicaid population would be more interesting to understand.

Nonetheless, the observation about public insurance is a hint that there may be some important cost containment business opportunities appearing as a consequence of the health reform law. Experience in Massachusetts indicates that as more people come onto the insurance rolls (including non-Medicaid patients getting access to subsidized commercial plans) they start using all services –not just the ER– more.

Even those who are aware that insured people are big ER users haven’t grappled with how to deal with the newly insured. For example, one of the ways payers and health systems try to control ER use is by making it convenient for patients to see someone at a community health center through open access scheduling and extended business hours. Yet many of their patients go to the emergency anyway, even during the working day.

Part of the problem (at least here in Massachusetts) is that hospitals have been so busy advertising that patients think that’s the best place to get care, whether for something basic or complicated. Why go to the doctor’s office or community health center when a high-tech hospital is available?

There’s a lot of work to do on this problem. My guess is some pretty good businesses will spring up to take advantage of the opportunity.

April 12, 2010

One thought on “ER cost control. The opportunity from health reform”

  1. I think they’ll need to put the newly insured into some kind of plan where you need pre-authorization. Hopefully that won’t be outlawed with the new health reform?

    My 24 y/o son has coverage through his job but if you go to the ER the co-pay is high.

    He had a bad run-in with some kind of poison ivy and needed to see someone but his PCP was out. So he calls the insurance company number (he’s a smart kid!) and they send him to a Pediatric Night time Clinic where they fixed him up in about an hour.

    After he’d been there I started noticing that they do have ads on buses all over town and they aren’t just for Pediatrics.

    He wouldn’t have known to go there if they hadn’t steered him that way.

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