July 16, 2012 — Limiting nonurgent visits to emergency departments (EDs) is not the best way to reduce costs, according to an article published online July 12 in the Annals of Emergency Medicine. Instead, EDs should focus on reducing admissions and improving efficiency in the ED.
Peter B. Smulowitz, MD, MPH, a physician in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues developed a framework for identifying categories of ED visits with the most potential for reducing costs.
"In the context of health reform, there is significant focus by public and private purchasers of care on reducing ED utilization under the premise that there is the potential for cost savings from preventing substantial numbers of potentially avoidable visits, along with their associated downstream costs. In the past, a variety of strategies to reduce ED utilization has been attempted, with mixed results," the authors write.
Dr. Smulowitz and colleagues divided ED visits into 3 categories (emergencies, intermediate/complex conditions, and minor injuries/illnesses) and developed a framework for estimating the potential savings that could be realized by changing the delivery of care provided to each group.
The authors estimate that minor injuries and illnesses make up from 12% to 40% of ED visits. Because ED care accounts for 2% to 4% of all health expenses, the authors estimate that these visits account for about 0.42% to 1.6% of overall costs if these visits are as costly, on average, as visits of higher severity. Reducing the number of these visits by 50% would reduce total health costs by only 0.24% to 0.8%. However, the estimate is probably high because visits for minor injuries and illnesses are likely to cost much less than higher-severity ED visits.
Moreover, expecting to reduce the number of these visits by 50% is unrealistic because that number of low-severity visits could probably not be diverted to other settings, according to the authors.
"[A]lthough seemingly 'low-hanging fruit,' diverting minor injuries or illnesses to other settings would not be expected to result in substantial cost savings, even with diverting up to 50% of visits. The cost of these visits is responsible for a small proportion of the 2% to 4% of total health expenditures accounted for by the ED," the authors write.
Intermediate/complex conditions make up from 31% to 57% of all ED visits. Yet the authors estimate that they account for a disproportionately large percentage of admissions, likely 75% to 80%.
To avoid overstating the potential savings from this group, the authors used a more conservative estimate that two thirds of admissions from the ED result from this category for their cost analysis.
Inpatient care accounts for about 30% of total health costs, and as 50% of admissions come from the ED, visits that result in admission make up about 15% of total health costs. Therefore, using the researchers' classification system, 10% of total health costs (two thirds of 15%) come from admissions of patients with intermediate/complex conditions. Reducing admissions in this group by 10% to 25% could reduce total health expenditures by approximately 1.0% to 2.5%.
True emergency visits are unavoidable and have little potential for savings. These visits require the care and expensive resources that are available in modern EDs.
"Even without taking into account the additional cost of treating some of the lower-severity conditions in an alternative setting, it would require diverting more than 80 patients with pharyngitis to save the money equivalent to a single avoided hospitalization," the authors write.
"However, the additional cost of establishing new urgent care centers or adding after-hours or weekend primary care availability is not trivial and is likely to substantially undermine or eliminate entirely the cost savings from diverting minor visits," they write.
Reducing Hospital Admissions Is Key
The authors note that a significant number of patients are admitted from the ED because of inadequate resources to care for them at home or in a short- or long-term care facility. Expanding the use of ED-based observation units could provide an alternative to admission for patients who need care longer than a typical ED stay, but who may not require hospital admission.
Closer communication between ED staff and case managers and community resources could also help facilitate care for patients with limited resources. The primary care team and medical home will play a critical role as the concept of accountable care organizations evolves.
The current system of financing emergency care will also have to be examined, write the authors. "The reality of financing emergency care in the health system of the future will need to balance the seemingly competing challenges of improving the value of ED care while preserving the availability of true emergency care," they write.
"Achieving cost savings will require a multifaceted approach: streamlined care within the ED, methods for preventing hospital admissions for patients already in the ED, and establishing pathways to effectively manage some of these visits in other sites of care," write the authors.
Dr. Smulowitz received a grant from the Charles A. King Trust Postdoctoral Research Fellow Program and the Eleanor and Miles Shore Fellowship Program for Scholars in Medicine. The authors have disclosed no relevant financial relationships.
Ann Emerg Med. Published online July 12, 2012. Full text
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