Recent studies have shown that many patients who visit emergency departments could be better served by other providers such as primary care and emergent care facilities.

Insurance Company Monitors Treatments Given in EDs

Anthem, the largest for-profit managed health care company in the Blue Cross and Blue Shield Association, recently announced some controversial changes to its policies regarding payments for emergency procedures. Specifically, the Indianapolis-based company has enacted a more stringent policy concerning which procedures will be covered during visits to emergency departments.

The shift is part of the company’s attempt to monitor and discourage what they deem to be unnecessary use of the ED by some clients. In its new policies, Anthem reserves the right to view medical records from the hospital before being sent a patient’s bill to gain a clearer sense of which ED procedures the patient has received. With more than 40 million Americans covered by Anthem, these policy changes mark a significant shift in the future affordability of emergency medical care across the nation.

While EDs are undoubtedly affected by overcrowding, studies reveal that reports of the uninsured exploiting the ER for non-emergency services have been significantly exaggerated in recent years. However, recent analysis does suggest that a significant percentage of patients — insured and uninsured — frequently visit the ER for non-emergency procedures that may be more affordable at clinics and other care outlets.

Providing Alternatives for Primary Care

A recent study of Baylor Scott & White Medical Center in Texas revealed that the leading health system significantly reduced the number of patients in neighboring EDs by creating a clinic within a local urban recreation center in Dallas. An analysis of BSW’s wellness center provides a concrete example of how patients, insurers, and care providers can benefit from the implementation of more affordable care methods for non-emergent needs.

BSW’s wellness center was designed to focus on population health management by providing members of a historically low-income community with access to low-cost primary care services. Of the 1,000 BSW patients surveyed, there was a significant — 21 percent — decrease in ER visits and a decrease in inpatient care visits of nearly 37 percent.

Besides addressing ED overcrowding, the BSW wellness center also provides a wide range of health-related services, such as making fresh produce available, which has contributed to a decrease in the number of visitors seeking inpatient care.

Researchers who conducted the BSW study emphasize that the success of the wellness center is an indication of a nationwide shift towards preventative care and holistic health management, a departure from the traditional emphasis on the treatment of chronic and pervasive illnesses.

Lowering Medical Costs

Helping a community manage its health care needs in a more sustainable way of lowering costs for insurance companies. Researchers report that ED costs dropped by 35 percent when working in connection with the wellness center. Inpatient costs also dropped by more than 50 percent. Addressing overcrowding of the ED gives faster access to patients who require emergency medical care, and gives more attentive, holistic, and reliable care to those seeking affordable access to quality primary care.

At d2i, we applaud BSW for its preventative and community-centered plan to reducing unnecessary ED visits. We also strongly feel that insurers should be using all the data they have to find ways of reducing their ED costs. By redirecting members who visit the ED more than five times per year to more cost-effective care settings for non-emergent events, they could lower the cost of care for themselves, their patients, and their providers.

Whether it’s understanding the impact of implementing a new program like the BSW wellness center or other programs to improve the capacity and quality of your services, d2i’s performance analytics solutions and services are being used every day by our clients to make their difference.