Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, Social EM

Health Policy Journal Club: Cheaper Isn't Always Better

37 urgent care visits are needed to offset a single trip to the ED 

Emergency departments were created to handle, well, emergencies. However, the emergency department has evolved from a high-acuity-only environment to a critically necessary safety net for the American health system. This safety net handles all acute needs, regardless of the severity of the issue or the patient's ability to pay. Despite the breadth of acuity, ED visits continue to be universally expensive. This has propelled private and public insurers to funnel lower-acuity needs to lower-cost alternatives, such as telemedicine and urgent care facilities. Have these efforts been successful in reducing costs?  This is the question asked by Wang et al. in their retrospective cohort study.

Wang and his team gathered impressively expansive data, analyzing the claims of approximately 20 million non-elderly patients per year covered by a national managed care plan from January 1, 2008, to December 31, 2019. Their data spanned all 50 states and every type of insurance including high deductible, HMO, and PPO. To mitigate confounding data, only previously defined "lower-acuity" conditions frequently seen at urgent care centers, such as rash, muscle strain, bronchitis, and urinary tract infection, were compared. Grouping patients by zip code, this study aimed to estimate the proportionate decrease in lower-acuity ED visits associated with an increase in urgent care center visits. ZIP codes were classified as having no urgent care use, intermediate urgent care use, or high urgent care use.

The study found that there was an obvious decline in low-acuity emergency room visits in ZIP codes that introduced a high-volume urgent care, dropping from 82 visits to 50 (39% decline). However, even in ZIP codes with no urgent care, low-acuity emergency room usage dropped from 110 to 76 visits (31% decline). An increase in 37 urgent care visits per enrollee was associated with a decrease of only a single lower-acuity ED visit. This ratio is particularly unsettling when you consider that emergency department visits cost an average of 10 times more than urgent care visits. The authors thus predicted that each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs – an overall net increase in spending!

A multi-pronged effort has been engaged by health policy makers, providers and private and public payors, to curb low-acuity, high-cost ED visits. Wang et al. indicate that utilizing urgent care centers to this end has potential but appears financially ineffectual at its current stage. There is an obvious need to change the way we treat patients with lower-acuity ailments without compromising quality of care or drastically increasing cost of care. While the increased access to unscheduled acute care that urgent care centers have created is a step in the right direction, there is an obvious need for innovative models of delivery that can increase this access without increasing the cost patients and insurers must shoulder, the latter of which inevitably are passed on to patients.


Abstract

Article: Wang B, Mehrotra A, Friedman AB. Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending. Health Aff (Millwood). 2021;40(4):587-595.

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008–19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that 37 additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.

PMID: 33819095


EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.