Plans explore numerous interventions to curb rising ED use

Avoidable emergency department (ED) visits cost the U.S. health care system up to $32 billion annually. Much of the care could be managed in a primary care setting, so plans are exploring a number of interventions including partnerships with primary care providers to rein in on ED costs. Despite this, consumers continue to seek non-emergent care in the ED.

Plans are betting that a PCP relationship will avert costly care use due to the member going to the PCP first or indirectly by having better managed health. While we see plans making extensive investments in primary care—through closer alignment or outright ownership—there remains a question of what the PCP can reasonably accomplish.

2019 Health Care Experience Survey shows no impact of PCP relationship on ED use

Using survey data from more than 3,000 consumers on their health care experience and utilization, we compared the rates of ED use among members with and without a PCP. Like other studies, we found that ED utilization was highest for members with at least one chronic condition and those enrolled in a Medicaid plan.

Medicaid enrollees and those with chronic conditions likely to use the ED

But the relationship between having a PCP and ED use is more complex. Members with a PCP were equally as likely to end up in the ED as their counterparts with no PCPs—even after controlling for having at least one chronic condition and plan type.

Members with PCPs likely to complete annual wellness visit but still end up in the ED

89% of members with a PCP reported having completed their annual primary care visit within the past 12 months, and yet 18% of those with PCPs ended up in the ED compared to 16% of those without. This means that ED visits for members with PCPs are complementary, rather than substitutionary, to PCP visits.

PCP-related interventions ineffective without guaranteed immediate access

When asked why they ended up in the ED, 30% of members claimed to have tried to go elsewhere and failed because they could not get in to see a physician or other clinician soon enough.

In addition to investing in primary care, plans must guarantee accessibility and immediate access to those primary care sites to effectively reduce ED use. A number of tested interventions, including offering extended hours and same day appointments have demonstrated reductions in ED use by up to 56 percent.