Addressing Patients’ Overuse of ER

3 Strategies to Reduce Unnecessary Hospital Emergency Department Visits

Experts agree that many emergency room visits are unnecessary, and some of
them estimate the number of unnecessary visits at 40%, 50% and higher.

Most primary care practices are open only during weekdays, and are closed at
night and on weekends, which causes patients to seek treatment at hospital
emergency rooms. Additionally, patients may not be qualified to judge what
constitutes an emergency, so they sometimes seek immediate help for problems that could have been treated at a later time by their primary care physicians.

The Centers for Medicare & Medicaid Services (CMS) issued an informational bulletin that presented three strategies for addressing unnecessary hospital emergency department (ED) usage:

Broaden access to services

Among other solutions, the CMS recommends medical homes and health homes because they typically offer extended hours, same day appointments and nurse advice lines. Some models include staffing for patient navigators that schedule appointments for frequent users.

Focus on behavioral health patients

High utilizers with behavioral health problems and substance abuse problems account for over 12% of all ED visits. CMS notes that this patient population can be targeted with case management, medical homes, housing and patient navigators.

Focus on frequent ED users

Frequent users are often defined as patients who visit the ED four or more times per year, and they account for about 25% of all visits. The CMS mentions a model that places an ambulatory care unit within the ED. They also recommend the use of Medicaid health homes for the most frequent users.

Some experts have suggested that hospitals should create an urgent care facility within the existing ER set up. Patients visiting the ER would be assessed by this urgent care facility — as a type of triage. Patients arriving by ambulance would be given immediate attention, but minor ailments would be treated by the urgent care facility, and true emergency cases would be referred to the emergency department.

How States are Adopting These Strategies

The CMS bulletin reports that some states are adopting Medicaid payment
strategies to reduce overuse of the ED. These states might provide lower levels
of payment for a non-emergency visit to the ED, based on a coding algorithm or a post-treatment review of the patient’s chart. This approach would require states to demonstrate that the payment strategy does not impede care and that safeguards are in place to provide alternate care outside the ED.

The Washington State Hospital Association created the Emergency Department Information Exchange (EDIE), which collects and shares information about emergency visits from 30 hospitals. The state was able to identify individual patients who were overusing the ED for minor complaints, and the system now includes tracking and notifications for those patients. They are not denied treatment, but they are strongly encouraged to seek other treatment options. EDIE reports the rate of use by these frequent visitors dropped by over 10%.

The Hawthorn Solution

Us at Hawthorn Physician Services understand the emergency medicine business model. We stay in-tune to the latest changes and recommendations and have developed superior reporting systems for maximizing reimbursements and improving cash flow.

To learn more about how our experienced team can help your Emergency Department be even more efficient, click here.

About Hawthorn

Hawthorn Physician Services Corporation is a privately-held, nationally-recognized healthcare revenue cycle management firm located in St. Louis, MO and currently operating in all 50 states. Hawthorn serves hospital-based medical practices, including pathologists, anesthesiologists, radiologists, hospitalists, emergency physicians, and radiation oncologists, plus office-based specialties, including internists, cardiologists, endocrinologists, wound care specialists, and infectious-disease physicians.

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