Patient Education About Emergency Department Utilization Will Be Key

New Health Affairs data is leaving researchers urging public health leaders to improve patient education about emergency department utilization.

This comes amidst the backdrop of health payers retooling ED claims evaluation processes that could leave some patients on the hook for the bill if the payer deems the visit unnecessary. Clear messaging about when a patient should and should not access the ED will require some nuance, as healthcare providers work to connect patients to good care for quality outcomes and payers strive to drive down healthcare costs.

The Health Affairs study, conducted by a group from Washington University School of Medicine, particularly looked at ED utilization during lockdown. Like other healthcare organizations, Washington University School of Medicine found serious decreases in ED utilization during the height of COVID-19 lockdown, even among high-acuity healthcare cases.

The team assessed a million non-COVID ED visits across 13 emergency departments in a major health system in St. Louis, Missouri. Overall, the team observed a 35 percent decrease in ED utilization during the lockdown, with decreases ranging between 40 and 52 percent, depending on acuity. Mental health ED visits saw the smallest drop, yielding 32 percent fewer visits during lockdown compared to analogous times.

Medicare patients had the smallest reduction in ED visits, with a 31 percent decrease, followed by Medicaid patients with a 44 percent decrease and privately insured patients with a 46 percent decrease in utilization.

“The 40 percent decline in ED visits of the highest acuity suggests that there were many ‘missing’ patients who should have sought ED care for conditions such as heart attacks and strokes,” the researchers said.

“Although further studies are needed to identify the consequences of delayed care at this level of acuity and scale, informing the public of health conditions that require timely ED care could be vital to reducing out-of-hospital deaths or the development of additional morbidities in the future.”

The researchers did note that ED utilization for low-acuity cases was more prevalent than anticipated for a pandemic lockdown. Low-acuity ED utilization only dropped by about 50 percent, even though it could be expected it would have gone down by much more.

Patient access to lower-acuity settings, like their primary care providers or urgent care clinics, may have been hindered during the pandemic and thus driven patients to continue visiting the ED for low-acuity needs.

The researchers said better patient education about care access—particularly, when an ED visit is and is not necessary—will be key.

“Furthermore, it is not always apparent at the outset of a particular constellation of symptoms whether it is of benign etiology or requires ED evaluation,” they wrote. “Therefore, policy makers and clinical leaders must inform the public of health conditions that require timely ED care and improve access to alternative, lower-risk settings of care.”

This comes amidst the backdrop of evolving ED claims evaluation processes from health payers. Recently, UnitedHealthcare announced an overhaul of this process, stating it would only provide coverage for emergency department visits if the claim is ultimately deemed emergent.

The payer said the policy is a key cost-containment strategy. The emergency department is notoriously expensive, with many patients accessing treatment that could be administered elsewhere. According to 2019 data from UHC, two-thirds of ED visits are avoidable, the payer said.

“UnitedHealthcare will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims,” the fact sheet stated. “The EDC Analyzer applies an algorithm that takes three factors into account in order to determine a Calculated Visit Level for the emergency department E/M services rendered.”

The logic behind the move tracks, but some patient advocates said these policies could be detrimental to patients. Patients may choose to forego care altogether out of fear of being hit with a large bill. And as observed in the Health Affairs study, that can be disastrous when the symptoms are, indeed, high-acuity.

The recommendation for better patient education about care access is an effective start. Framing those education strategies with health equity in mind will be key, as many public health campaigns only reach a typically more affluent patient population.

Offering patient education in multiple languages and in a culturally competent way is one step forward. However, it will require deep community health partnership to generate the patient trust needed to heed patient education messaging about care access and ED utilization.