Emergency reform: It’s time for change in our healthcare system

Anthem’s decision to deny reimbursement for some (but not all) ER visits it deems non-emergencies has raised the hackles of providers and Congress alike. Yet as a former executive with United Health Group, I understand Anthem’s motivation to rein in inappropriate use of the emergency room. 

As one widely cited study noted, the average cost of an ER visit is $1,233. And that’s just a baseline; the bills for other ER visits can reach stratospheric heights, like the $12,596 bill a Kentucky woman received in 2017.

Still, we’re currently experiencing what could be the worst flu season in a decade. Such a policy could compel many enrollees to avoid the ER even if urgent flu symptoms become apparent. And at any time of the year, this policy is precarious, such as for adults who may or may not be having a heart attack. The signs can be confusing; many may forego a cautionary trip to the ER for fear of a bill they won’t be able to pay. That’s hardly an advisable choice in a country where heart disease is the No. 1 killer.

Instead, we should strive to find ways to reduce ER costs that don’t put patients in danger — or in debt. As was also mentioned in the above report, the average cost of an ER visit is now higher than the average month’s rent.

{mosads}We should look to those healthcare insurers that are taking alternative paths to decrease ER claims.

In just one example, an Arizona health plan, CareUnify, has reduced ER visits for some member populations by up to 45 percent, in large part by making sure these members are receiving more regular access to primary care services, and by strengthening care coordination.

Another Arizona-based health plan, Mercy Care, is also keeping its members — people with severe mental illnesses — out of the hospital by identifying critical care gaps and connecting them to more frequent primary care and preventative services. This includes primary care physicians located on premise at behavioral health clinics.

An additional observation here: People who suffer from mental illness historically experience great difficulty accessing basic healthcare. This has led to a devastating “mortality gap” that takes decades off their lives compared to the general population, largely because of untreated chronic conditions aggravated by poor health habits.

So supplanting avoidable ER visits with more consistent primary care services is one workable approach for all patient populations. However, primary care providers need some help of their own in identifying which patients are due for which preventative health services — like a heart health screening that would identify of a potential problem, well before it balloons into an ER visit.

Here’s where healthcare insurance companies can act with compassion and fiscal prudence.

Instead of waiting until a claim for an ER visit comes in, why not work with physicians to identify the patients most likely to end up in the ER if they don’t get certain services soon? Instead of owning patient risk analysis, why not expand this clinical insight to providers who can quickly act on it?

That’s a lot easier now than it used to be. Shared data platforms pull data from physicians, mental health professionals and insurance companies, plus health information exchanges, pharmacies and other entities, to present a full and close to real-time picture of patient health. Analyzing the data, these platforms can then spot which patients are due for any number of preventative services.

They can also alert when a patient does end up in the ER. Too often, primary care physicians don’t learn about such incidents until weeks later, if at all. By then, the patient has wound up back in the hospital — something that could have been prevented if he or she had received prompt follow up care from the primary care physician after the first ER admission.

Healthcare insurers should supply these platforms to physicians, rather than expect busy physicians to take the lead and find these solutions on their own. But it should be crystal clear that the physician is in charge of managing patient care, always. The point isn’t to dictate to physicians who gets what healthcare services. And it certainly isn’t to deny services to patients. It’s to see that patients get the healthcare most appropriate for their needs.

Koorosh Yasami is co-founder and chief strategy officer for HealthBI, a population health technology company of the Equality Health LLC. Prior to that, Yasami was a senior director of business intelligence with United Health Group.