Unfortunately, many people have not planned ahead for what to do when an urgent medical situation arises. Awareness of options like telehealth, retail and urgent care clinics, and understanding the types of conditions that are appropriately evaluated and treated in each of these settings can lead to better choices of where to seek care in an emergency.

Use of the emergency room (ER) for services that could be provided in a lower-cost setting is often portrayed as an issue related to being uninsured or under-insured. But, a 2018 study estimated that there are 18 million avoidable emergency room visits annually that result in $32 billion in additional costs to the healthcare system among commercially insured individuals.1 Our Employee Health Trends 2021 report showed a decrease in the rate of ER visits for common conditions that can generally be treated in a less costly setting during the first nine months of 2020 compared with 2019.

Following an initial 67% decrease in the rate of these visits at the start of the pandemic (April 2020), year-over-year rates continued to be over 30% lower in the fall. While this is great news, we need to ensure that these rates continue to decrease as the pandemic resolves.

Cost Is a Big Issue, But It’s Not the Only Issue

A recent report in the New York Times documented how an ER in Greenwich Village charged patients over $3,000 for COVID-19 testing – about 30 times greater than what is typically charged. While this example is more extreme than most, we found that the cost of an ER visit is substantially higher than an office or urgent care visit for the same condition.

Springbuk 2020 data in the table below shows differences in median cost using net payment by site of service for several common conditions that can generally be treated in an office or urgent care setting.

But cost is not the only issue. Patients are likely to benefit from receiving care from their primary care physician (PCP) when feasible. PCPs are more aware of a patient’s complete medical history, including allergies and medications. Because of this, they can assess the patient’s current symptoms in the context of known issues and may be less likely to prescribe medications that may adversely interact with current medications.

Over 90% of ERs report issues with overcrowding. While much of the problem is due to boarding individuals in the ER while waiting for open hospital beds, avoidable ER visits also contribute to the issue.2 Because this overcrowding is associated with poorer outcomes for the most emergent patients and more medical errors, it’s in everyone’s best interest to reduce unnecessary ER use.

Why Do People Choose the ER?

Studies performed to understand why individuals choose to receive care in the emergency room for issues that could be treated in less costly settings have uncovered several factors that influence these decisions.3-6 Among those with commercial insurance, common reasons include:

  • Uncertainty of the seriousness of symptoms and which sites of service can provide appropriate care: A 2017 survey by a New York-based urgent care provider showed that only about half of over 2,000 respondents could correctly identify urgent care centers as an appropriate option for some common conditions seen in the ER. Conversely, about thirteen 13 percent did not recognize the ER as the appropriate site of care for symptoms related to heart attack or stroke.3
  • Primary care access issues: Another common reason for commercially insured patients to seek care in the ER is the inability to see their PCP either because they are seeking care after hours or because their PCP cannot see them in a timely manner. While some of those seeking care after hours are doing so due to an urgent situation, others seek after-hour care because they cannot take off time from work during the day to receive care for non-urgent issues.
  • Need for reassurance: The combination of uncertainty of the seriousness of symptoms and primary care access issues may result in use of the ER by individuals who are mainly looking for reassurance that their symptoms are not serious.
  • Convenience: Some individuals like the convenience of “one-stop shopping” being able to receive evaluation and diagnostic testing during a single visit.
  • Coverage misunderstandings: Patients are sometimes unaware that their coverage includes telemedicine services or services from retail clinics.

The Role of Employers in Helping Employees Make Better Care Choices

Understanding why employees and their family members seek care in the emergency room informs strategies to reduce unnecessary use of the ER.

  • Provide educational materials and infographics (such as this and this) to help employees and their families understand the necessary level of care for common conditions and symptoms, using multiple distribution channels throughout the year rather than only at the beginning of the benefit period.
  • Encourage employees to plan in advance for urgent and emergency health situations. In addition to knowing the office hours for their primary care physicians, employees should be encouraged to prepare for emergencies by determining hours of service for retail clinics, urgent care clinics, and emergency rooms that are within a reasonable distance. Be sure that they also have information for nurse advice lines and telehealth services readily available. Telehealth may be particularly useful when the main reason for seeking care is reassurance.
  • Be sure that your employees are aware of the differences in what they will pay based on the site of service. While many plans use higher out-of-pocket payments for members to discourage ER use for non-urgent issues, these will only be effective if employees are aware of out-of-pocket payment differences when selecting where to receive treatment.
  • Encourage employees to consider extended hours of operation when they select a PCP. Encourage onsite clinics and primary care physicians in-network to expand office hours to evenings and weekends.

How Springbuk Can Help

Springbuk’s health data analytics platform enables you to determine conditions driving emergency room use. We also help identify individuals and conditions responsible for avoidable or preventable emergency room use, individuals with frequent ER visits, and track the impact of programs you implement with a few clicks.

Understand recent use - Springbuk Answers allows you to track emergency use rates compared with a benchmark and to quickly identify diagnoses responsible for the most ER visits or spending.

Create strategies based on drivers of preventable ER visits – Assessing different categories of potentially avoidable ER visits, including visits for flare-ups of chronic conditions, non-emergent conditions, or acute conditions that could be treated in a primary care setting will inform best strategies to reduce these visits. Frequent ER users can be targeted for personalized education.

Understand the impact of strategies you employ -
Springbuk Timeline is a unique feature that allows you to keep track of implemented strategies and visualize impact.

Educate and Encourage

Most unnecessary use of the ER by commercially insured individuals is due to an inability to assess the seriousness of their condition and lack of knowledge about the capabilities of less costly care settings. Educating employees and encouraging them to plan in advance for the potential of an emergency are strategies that will result in better choices for treatment. Springbuk can help you identify avoidable ER visits and monitor impact of strategies to reduce them.

For more insight into Telehealth utilization trends, download the 2021 Employee Health Trends Report.

Or, read the posts in this series on trends:

4Coster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med. 2017;24(9):1137-1149. doi:10.1111/acem.13220
5Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis. J Gen Intern Med. 2019;34(11):2610-2619. doi:10.1007/s11606-019-05128-x

Meet the Author: Janet Young, M.D.
With more than 30 years of experience, Janet Young has provided clinical expertise to the development of healthcare analytics used in provider, payer, employer, and government sectors. Previously, Janet served as a Lead Clinical Scientist at IBM Watson Health, guiding clinical content development related to new models, methods, and analytics using claims, EMR, Health Risk Assessment, and socio-demographic data. 

Janet joined the Data Science and Methods team at Springbuk in Dec. 2019, and has been responsible for clinical oversight of methods and models. Janet received her M.D. from Yale University School of Medicine.