Unnecessary emergency department visits cost $47B a year, report finds

NYC Health + Hospitals has redirected more than 2,400 911 calls since the public health system launched its telehealth service last March.

NYC H+H works with city emergency medical services via its virtual ExpressCare platform to evaluate low-acuity 911 callers who may not need an ambulance. About 1,300 of those rerouted calls were during an ambulance ride directed toward a NYC H+H emergency department, where the patient decided with an emergency medicine provider to not go to the hospital.

"Something ailing the U.S. healthcare system is the lack of primary care being the first point of contact," said Dr. Eric Wei, chief quality officer at NYC H+H. "Core to our strategy here is to shift people away from the ED. Even though we have grown our primary care physician network and expanded hours, this is a product of a broken system where people have learned that the ED is the safety net of the safety net."

Many Americans use the emergency room by default. Whether there was a communication disconnect between insurers and patients, it was overly complicated to find a doctor, patients needed after-hours care, they lost their jobs and associated coverage, or patients were worried about their citizenship status, many head to the ED even if it isn't an emergency.

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This has led to at least $47 billion in unnecessary healthcare spending, the consulting and IT service firm Accenture found in a new report. Those with a chronic condition were twice as likely to have received care in the emergency room over the last year than people who were more familiar with the healthcare system, according to Accenture's survey of 12,000 Americans conducted in February and March.

Meanwhile, low healthcare system literacy has increased from 52% in 2017 to 61% in 2021, according to the report. Those who don't know the difference between in-network and out-of-network care have low healthcare literacy, for instance.

"When asked about the likelihood of getting the COVID-19 vaccine, people with the highest level of healthcare system literacy were 25% more likely to be very willing to get it than people with low system literacy," the report reads. "This trend creates the potential for a 'perfect storm' of unvaccinated people who are more vulnerable to the virus."

Freeing up hospital capacity has been even more important as COVID-19 patients—the vast majority of which are unvaccinated—take up so many beds. Most hospitals in Texas are operating at roughly two-thirds of their bed capacity, one rural northeastern Texas hospital operator said. Some emergency rooms are so swamped, patients are being sent home to be monitored by emergency services teams.

While ER utilization plummeted during the pandemic, volumes are starting to rebound as patients, often more acute, resume deferred care, Wei said.

"Volumes are starting to come back, and they are definitely more serious or concerning cases," he said.

Some hospitals built emergency department/urgent care combination facilities to triage patients appropriately. ProMedica, for example, will open a freestanding emergency department in Toledo, Ohio next month that will include an urgent care. NYC H+H has been opening more urgent care centers, coined ExpressCare, at its hospitals.

Santa Clara Valley Medical Center, a level one trauma center in San Jose, California with an ED that serves about 100,000 patients a year, recently opened Bascom OB-GYN urgent care clinic, in part, to free up inpatient beds. It has also boosted its weekend staff to get patients who are ready to be discharged out of the hospital sooner.

SCVMC scores patients based on symptoms, diagnoses and vital signs. Providers then send them to an urgent care, an outpatient facility, home or the emergency room based on their acuity, said Dr. Sanjay Kurani, medical director of inpatient medicine at SCVMC.

"We work with a vulnerable population at SCVMC; many use the emergency department as a primary provider," he said. "The Affordable Care Act has been incredibly helpful in expanding Medi-Cal—the key going forward is that vulnerable patients get connected to a primary-care physician. We want to make sure we don't have a revolving door in the ER—that is still a work in progress."

Telehealth has also eased capacity constraints. NYC H+H's virtual ExpressCare has helped treat more than 16,000 patients in total since last March. Many sought medication, refills and other primary-care services, said Dr. Shaw Natsui, assistant vice president of emergency services at NYC H+H.

"The socioeconomic dislocation of COVID-19 means that we saw patients who would've otherwise gone to the ED as a last resort to fill their insulin," he said.

The most common symptom associated with hospital admissions at SCVMC is chest pain. The medical center has implemented a new blood test that reduced one-day hospital stays for chest pain by 70% over the past year, Kurani said.

Typical troponin tests, which measure proteins released into the blood when the heart muscle has been damaged, take six hours. But a high sensitivity troponin test can produce results in half the time.

"Having a patient wait in a highly valuable bed for six hours is not a good utilization of resources. We need those beds for strokes, heart attacks and traumas," Kurani said. "We could save about 400 bed days a year by using this new tool."

Hospitals will continue to try to connect patients with primary-care physicians, one of the biggest but largely unrealized aims of the Affordable Care Act.

About 30% of virtual ExpressCare patients at NYC H+H scheduled a primary-care visit within 90 days of the appointment, Wei said.

"We want that to keep going up," he said. "Everyone has a right to a primary-care physician. We'll continue to expand primary care and NYC Care to fulfill that vision."