Emergency department (ED) visits are often time-consuming, traumatic and costly. So why is there such high overutilization of this channel?
The reasons are varied and complex. They are common because some see them as the most efficient way to get medical care.
In the ED, patients receive a litany of tests, some of which are likely unnecessary. They may see this as more efficient than going to a primary care physician and receiving referrals to specialists for testing. The problem is this approach drives up costs, and more tests don’t always correlate to quality and effective care.
Lack of access to or relationships with primary care physicians keeps many from going this route as well. They don’t have reliable coverage, so the ED is the better alternative. Social determinants of health (SDOH) and general disengagement also play a role.
What does this cost? Research on avoidable emergency department visits concluded that it cost the U.S. health care system $32 billion annually. In addition to these monetary strains felt by Medicare and Medicaid, patient outcomes aren’t necessarily high quality. Emergency room clinicians work in a fast-paced environment, so it’s not the same as an office visit with a physician that knows a patient’s history. State Medicaid Agencies categorize these as unnecessary, but what does that mean precisely?
Categorizing “unnecessary” emergency department visits
Receiving care at emergency departments is justified in acute situations, and sometimes the patient cannot tell the difference. However, many visits to the ED are “unnecessary.” Unnecessary can mean care that could have been rendered in another setting. It can also mean an emergency department visit was avoidable if patients had followed discharge instructions and taken medications as prescribed. Nonadherence to care plans can land patients back in the hospital, creating more costs.
Preventing these unnecessary visits is a priority for plans to ensure spending and care are effective, but standard interventions may not deliver better numbers.
Standard interventions may not reach emergency department overutilizers
Emergency department visits are expensive, potentially wasteful and don’t provide the best outcomes. For these reasons, states and Managed Care Plans have made it a priority to reduce unnecessary ED visits.
Managed care plans deploy several strategies to target emergency department overutilizers. The first step is to identify these members and understand what the data reveals.
For example, members with certain chronic conditions can end up at the hospital because they aren’t following their treatment plan or medication regimen.
One intervention is to provide members with information on how to better manage their diseases such as the importance of staying current with medications and outpatient office visits. You may include resources for mail-order or home delivery pharmacies to ensure members can easily obtain their medications. This type of communication can be a good reminder and spur some members to maintain better habits.
Unfortunately, this is not enough for all of your members. Some are too disengaged from your plan and their health. For this group, you need a new strategy that considers their disengagement. In many cases, what’s behind their disengagement and repeated trips to the ED is chronic loneliness. To address this loneliness, you need empathy-driven innovations.
What is empathy-driven innovation, and how does it prevent emergency department overutilization?
What other avenues do Medicare and Medicaid plans have to reduce emergency department visits? Empathy-driven innovation is a new strategy to pursue.
An empathy-driven innovation describes a category of interventions focusing on treating members with empathy, understanding their SDOH needs and addressing chronic loneliness.
The medical community wants to provide empathy. However, it’s hard to do it at scale. That’s why the innovative aspect of an empathy-driven program is how it marries technology with human connection. This combination provides both the human touch and the ability to scale.
To implement such a program, you’ll need data on your members, identifying high utilizers of the emergency department, those with SDOH needs and the chronically lonely.
Address SDOH and loneliness
By learning about SDOH needs and loneliness, you’ll be able to define members most at risk for emergency department visits. From there, you can present resources to fill the gaps.
Medicare and Medicaid both have ways to close the SDOH gap. The Centers for Medicare and Medicaid Services (CMS) issued a new roadmap to address SDOH for Medicaid recipients in 2021. CMS expanded coverage for SDOH for Medicare members in 2019. The programs are available, and some are already seeing results. According to research from PwC, a Meals on Wheels program correlated to fewer hospitalizations and lower health care costs in the Dallas area.
The second part of the program is finding members who suffer from chronic loneliness. This medical condition impacts both physical and mental health. It’s more than solving for social isolation and companionship.
Loneliness drives overutilization, address it with empathy
Being chronically lonely is more than a state of mind. Research links it to the risk of early death and various diseases. Further, lonely members use their health plans differently. They lack social relationships and are more likely to head to the emergency department over other care settings. A clear example is a report that 80 patients showed up in Dallas emergency departments a cumulative 5,139 times in one year due to loneliness.
These members will benefit most from empathy-driven interventions. They can interact with the technology to provide feedback. Then, they can access human connection via compassionate support centers (CSCs). They can talk about any subject with no judgment. The result is enhanced member engagement, decreased ED visits, increased visits in other care settings and greater adherence to treatment plans.
The Pyx Health solution combines these things, and our data shows that members in the program have reduced loneliness scores, report fewer depressive symptoms and increased use of community-based resources.
Learn more about empathy-driven innovation and its roles in member engagement.
