Unnecessary ED Visits
There has been much focus lately over unnecessary ED visits, with insurers in several states refusing to pay for necessary ED care. This type of payment refusal hurts patients that present to the ER for legitimate reasons.
Refuting to this assessment, in a recently published study, researchers found that only “3.3%” of visits to the emergency department (ED) “are truly ‘avoidable.’” They examined “data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 to 2011 that included…424 million emergency department visits.” Published online in the International Journal for Quality in Health Care, the study’s conclusions show what ED clinicians already know: that acuity has increased significantly over the years, and that most patients who present to the ED do so for a good reason.
They defined ‘avoidable’ emergency department visits as patients that did not require any diagnostic or screening services, procedures, or medications (ESI 5) and were discharged home. As you might expect, the study showed the most common ‘avoidable’ ER visits included alcohol, mood, and dental conditions. In fact, alcohol and mood disorders (e.g. depression and anxiety) accounted for 6.8% of ‘avoidable’ visits, while dental conditions accounted for another 3.9%.
However, they found that only 10.4% of visits with alcohol disorders, 16.9% of mood disorders and 4.9% of dental conditions were ‘avoidable.’ This shows that while these conditions were the most common ‘avoidable’ ER visit discharge diagnoses, the majority of patients with these conditions still required some form of diagnostic or treatment service, meaning they should not be classified as unnecessary ED visits.
Lead study author Renee Hsia, MD, MSc, of the Department of Emergency Medicine at the University of California, San Francisco addressed this. “We found that many of the common conditions of ‘avoidable’ emergency department visits involved mental health and dental problems, which ERs are generally ill-equipped to treat.” “This suggests a lack of access to health care rather than intentional inappropriate use is driving many of these ‘avoidable’ visits. These patients come to the ER because they need help and literally have no place else to go.”
This challenges the insurance company belief that there are a huge number of unnecessary ED visits, according to Becky Parker, MD, president of the American College of Emergency Physicians (ACEP). In her announcement, Dr. Parker said, “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that – myths.”
Until there is improved access to outpatient behavioral health and dental care (and available off-hours!), these patients will continue to present to the ED. They have nowhere else to go. This is why the ED is called the “safety net” for the US healthcare system.
While it is true that insurers should pay for necessary services, it is also true that many patients with minor conditions (certainly ESI 4 and 5) could be treated in less-costly outpatient settings. The problem is with the language (unnecessary, avoidable), the definitions, and the desire to deny payment. Insurers should focus on educating their insureds to access the most appropriate, lowest cost facility for minor care. Most visits are not avoidable, but that does not mean that every sprained ankle patient needs a Trauma Center.
Link to the study: https://academic.oup.com/intqhc/article-lookup/doi/10.1093/intqhc/mzx081