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Claims Data Reveals 2 Million 'Potentially Preventable' ED Visits in NY

By John Commins  
   April 08, 2016

An analysis of New York State Department of Health data identified 10 common low-acuity conditions. The estimated cost of the potentially avoidable ER visits is $1.3 billion, according to Excellus BlueCross BlueShield.

More than 2 million trips to hospital emergency departments in New York state costing $1.3 billion could have been avoided if patients had sought treatment for 10 low-acuity conditions in less-expensive care venues, according to an analysis by Excellus BlueCross BlueShield.

The Excellus study examined New York State Department of Health data on 6.4 million ED visits in 2013 and identified 10 common low-acuity conditions that were "potentially preventable" if the patient had sought treatment in a primary care physician's office, an urgent care center, or by using telemedicine.

Jamie Kerr, MD, medical director, Excellus BCBS, says the $1.3 billion cost was an extrapolation of Excellus BCBS upstate New York claims data from 39 counties. She says spending is probably higher because costs in the New York City area are higher.

The 10 common low-acuity conditions included bumps and bruises, joint aches, ear aches, headaches, sprains, strains, and sore throats. The $1.3 billion estimate was built on the assumption that each potentially preventable ER visits cost nearly eight times the cost of seeing a doctor, 3.5 times the cost of an urgent care center visit and about 15 times the cost of using telemedicine, which averages about $49.

Kerr says there's no simple answer for what is driving these potentially preventable ER visits, but it's not a new phenomenon. "The use of emergency rooms for low-acuity clinical problems has been going on for years. I don't want to imply that there is a sudden acute rise," she says.

"We have done some outreach in our communities and it is a combination of factors. One is that there are in some areas shortages of primary care physicians. The other is that clinical problems sometimes begin in the after-hours timeframe," she says.

"Physicians can't work 24/7. Some of it is access to primary care, but also access to primary care in the evenings and the weekends. Some of it is the fact that patients don't have a regular relationship with a primary care physician. Sometimes there is lack of knowledge that there are alternatives to an emergency room if you have a clinical problem and you recognize that you need to be seen and your doctor may not be available."

Mandatory Coverage for Telemedicine

Effective Jan. 1, health insurers in New York state were required to cover telemedicine visits by patients enrolled in their commercial products. "The telemedicine infrastructure is emerging, but it's not been fully adopted," Kerr says.

"We have a very mature healthcare delivery system and the challenge will be how do we incorporate telemedicine technologies into our current delivery systems and physician practices when applicable and what role will it play in the evaluation of what appear to be common primary care clinical problems that could be potentially handled through a virtual visit."

Kerr says many patients don't understand when and where urgent care and telemedicine services are available, but that payers and providers are working to address that.

"We've been working in partnership with a terrific group of physicians in upstate NY through the medical societies on educating patients about emergency rooms and low-acuity visits. We have a physician community that is actively engaged, and public awareness campaigns, and they have partnered around communicating with patients," she says.

"I would say there is more work for all of us to do. All of us have a role. Health plans, physicians, and patients have a role."

Excellus ER Infographic by HLMedit

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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