ER Visit Reduction Efforts Best Focused on Non-Emergent Cases

Thursday, July 23rd, 2009
This post was written by Melanie Matthews

Dr. James Glauber, medical director for Neighborhood Health Plan of Massachusetts, explains why his organization no longer targets “frequent flyers” in programs to reduce ER use.

When intervening to reduce ER visits, one of the decision points a plan needs to make is whether they’re going to focus on frequent ER utilizers — who make up only a small percentage of total ER use — or whether they’re going to adopt a broad-based strategy to target ER use among the 90 percent of the population that is visiting the ER occasionally.

We’ve made some observations in regard to using case managers to target frequent ER utilizers. It’s difficult to find and engage these individuals regarding their ER use patterns. We outreach them sometimes weeks or months after their last ER visit. Often they report that the reason they went to the ER was because they were directed to go by their primary care site, either because of the nature of their condition or the fact that there weren’t any available appointments. Often, they do not appreciate being contacted regarding their ER use. In addition, it’s unlikely that they will remain high ER utilizers the following year.

The Massachusetts Division of Healthcare Finance and Policy conducted an analysis of ER use, based on a database of all the ER visits that occurred in 75 ERs across the state over a two-year period. They defined frequent use as greater than or equal to five ER visits per year, in the baseline year of 2002. They identified the group of frequent ER utilizers and determined the likelihood that they would remain a frequent utilizer in the following year. They found that only 28.4 percent of frequent utilizers remained frequent utilizers in the following year, and 25.1 percent had no ER visits the next year. The remaining group — slightly less than 50 percent — was just occasional users in the following year. They did, however, identify a subgroup of frequent users who also visited four or more different ERs in the following year. This group of “frequent ER travelers” tended to visit the ER for pain-related diagnoses such as lumbago, headache, migraine and tooth pain. These frequent ER travelers were much more likely to remain high utilizers in subsequent years.

Based on this information, we are no longer investing resources in targeting high ER utilizers. We’ve focused the majority of our efforts on interventions to reduce ER use for non-emergent conditions among the occasional ER utilizers in our population. Our strategy is to provide resources and information to enhance members’ self-care decision-making. The strategies we’re using are low-touch but broadly based — at the very least they will not do any harm. Also, they have the potential for collateral benefit in terms of giving members access to information that may more broadly benefit their health and healthcare. To be effective, these strategies require ongoing marketing to reach the targeted audience.

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