Emergency department (ED) visit rates in the United States have been rising over the past 2 decades, outpacing population growth.1 These visits are portrayed in the lay press as unnecessary visits that must be reduced or avoided. Yet a growing body of evidence indicates that most ED visits are medically necessary and that EDs serve as a critical source of care for high-risk patients, including those with comorbid mental health diagnoses, substance use disorders, and poor social determinants of health. Insurance companies and other payers have a years-long history of attempting to dissuade individuals from using the ED by refusing to pay for their visits—after the visit occurs—if it is categorized as nonemergent. In 2012, the Washington State Health Care Authority attempted to pass legislation stating they would only pay for ED visits for Medicaid patients that they deemed to be medically necessary. More recently, the health insurer Anthem implemented a similar policy, evaluated by Chou et al.2 Their study examines this policy, which denies payments for ED visits based on a patient’s discharge diagnosis. At first glance, this idea makes sense: no one wants to pay for an ailment that could have been treated in a less expensive setting. However, policies that deny payments based on discharge diagnosis put vulnerable patients at risk and have significant flaws.
First, there is no way to make an accurate determination of medical necessity for emergency care in advance. In a previous study,3 my colleagues and I examined whether a patient’s symptoms at presentation to the ED could be labeled reliably as a nonemergency based on the discharge diagnosis—the diagnosis that Anthem is currently using to determine medical necessity. We found it was impossible. We restricted our analysis to include only discharge diagnoses that were categorized as nonemergent or primary care–treatable.3 We linked this group of nonemergency diagnoses back to their corresponding chief concerns from when the patient had arrived at the ED. When we examined the universe of outcomes related to these chief concerns, we found 12.5% of patients with these presenting concerns required admission to the hospital (including the intensive care unit), and 3.4% went directly to the operating room. As emergency clinicians, we wait until after a workup to assign a discharge diagnosis: this workup is based on a detailed history and often involves blood work, imaging, and multiple hours of observation. That the same presenting symptoms that resulted in some patients going to the intensive care unit and others being denied coverage because the visit was considered unnecessary makes clear the impossibility of patients judging medical necessity.
While few would argue that some proportion of patients who visit the ED could in theory be cared for in other settings, several recent studies have shown that most patients who seek care in the ED have urgent concerns.4 Their decision to come to the ED is rational. It is clear (even by Anthem’s own estimates) that the vast majority of ED visits are not unnecessary. Other studies have shown that individuals feel ED-based care is of higher quality and that a wider variety of services are more accessible.5 The nation’s primary care system is overstretched: outside of a few contained systems (eg, Kaiser) most primary care systems are unable to meet patients’ need for timely care. And an additional force is at work that deserves more attention: outpatient clinicians are referring their patients into EDs at high rates. Our recent study6 found that about 25% of US adults with 1 or more ED visit in the previous year had been referred to the ED by an outpatient clinician. Primary care clinicians recognize that the ED can facilitate advanced evaluations and observation to help determine the need for hospitalization—functions that often cannot occur in busy outpatient clinics.
Perhaps it is not surprising, then, that Anthem is coming to terms with the fact that their policy to deny payment is not working. The insurance company is learning what we already know from peer-reviewed research: most patients in the ED are there for good reasons, and it is hard to prove otherwise. And despite a proliferation of programs aimed at reducing ED visits using mechanisms other than denying payment, lowering ED use has proven an elusive goal.7 To make a dent in ED use, our health and social care systems must improve access to primary care, behavioral health, and community-based resources. This type of investment will take a large amount of political will over many years. The United States spends more than any other Organisation for Economic Co-operation and Development nation on health care. However, it ranks near the bottom on the percentage of gross domestic product spent on social programs such as employment and housing—services that have been shown to directly affect health outcomes.8 Until significant and sustained investment in community-based health and social services becomes a priority for our nation, EDs will remain the de facto safety net.
Pushing people out of our nation’s EDs is myopic. Policies like those put forth by Anthem place an unfair burden on patients. Discouraging people from seeking needed care will lead to higher downstream costs for untreated illness and defeat the insurer’s (misguided) attempt to lower health care expenditures. While ED visits in and of themselves account for a relatively small share of overall health care spending (2%-6% depending on the study9), inpatient care is one of the leading drivers of health care costs nationwide. A recent RAND report10 found that ED clinicians are now decision makers for more than 50% of all admissions to hospitals in the United States. Any ability to help reduce hospital admissions sits squarely on the shoulders of ED clinicians. We are already experts in attempting to “turn patients around” so that they do not require admission to the hospital: of 136.9 million ED visits in 2015, only 9% were admitted to the hospital. Yet there are other untapped areas that can lead to lower downstream costs and improved outcomes for our patients. Testing for HIV, screening and initiation of medication-assisted treatment for substance use disorders, information technology platforms that facilitate real-time care coordination for high-risk patients, and increased focus on addressing social determinants of health, including homelessness, are increasingly seen as fundamental to emergency care. Rather than viewing ED visits as adverse outcomes that must be reduced, we can try to optimize these visits and the myriad functions EDs have the potential to provide. Emergency departments have become an invaluable health and social service hub for patients and clinicians alike; the next step is to fund, implement, and research the impact of cutting-edge emergency services that can provide value for our patients and our health care system. Our federal mandate is to provide care for all comers. We have 136.9 million chances to positively affect patients every year. Let us do it right.
Published: October 19, 2018. doi:10.1001/jamanetworkopen.2018.3728
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Raven MC. JAMA Network Open.
Corresponding Author: Maria C. Raven, MD, MPH, MSc, Department of Emergency Medicine, University of California, San Francisco, School of Medicine, 505 Parnassus Ave, San Francisco, CA 94143-0209 (maria.raven@ucsf.edu).
Conflict of Interest Disclosures: Dr Raven is an elected member of the California Chapter of the American College of Emergency Physicians Board of Directors and a volunteer member of the clinical advisory board for Collective Medical, creator of an information technology platform that allows emergency providers to view visits for frequent emergency department users outside of their own facility and to develop care guidelines to help coordinate care.