Four Tips for Taming Runaway Emergency Room (ER) Expenditures
The average cost of an urgent care visit is almost 71% less than a typical visit to the emergency room ($155 vs. $583) for treatment of the same illness or injury. (It’s also cheaper than a typical primary care visit, albeit not by much ($155 vs. $165.) In another study in 2013, the National Institutes of Health (NIH) showed the median cost of an emergency room visit was $1,233, though in some localities it rose as high as $2,168.With such a dramatic difference in the cost of care by facility, employers have a vested interest in making sure their employees know when they should use Urgent Care vs. the ER vs. calling 911 or an ambulance. But that’s simply not happening.
A Closer Look At The Costs
In a 2013 study by Truven Health Analytics, it was found that over 70% of ER visits made by individuals with employer-sponsored healthcare were for non-life-or-limb-threatening medical issues, and could have been handled appropriately in an Urgent Care facility.
For some of these most common non-life-or-limb threating illnesses seen in the ER, the difference in average cost is striking:
- Emergency Room vs. Urgent Care Costs
- Allergies: $345 / $97
- Acute Bronchitis: $595 / $127
- Earache: $400 / $110
- Sore Throat: $525 / $94
- Pink Eye: $370 / $102
- Sinusitis: $617 / $112
- Strep Throat: $531 / $111
- Upper Respiratory Infection: $486 / $111
- Urinary Tract Infection: $665 / $112
While it may seem obvious, even to a layperson, that none of these issues are likely to constitute a danger to life and limb, except in very rare circumstances, patients are nonetheless being treated for these illnesses in inappropriate settings.
Who Suffers? You Might Be Surprised
From a cost perspective, one might assume that employees and patients are the ones who bear the brunt of these excessive expenditures, but that’s not always true.
While some employer health plans are (wisely) set-up to attach higher deductibles and co-pays to ER visits, we’ve come across more than our fair share of plans where the employer has failed to create a large enough disparity between the cost of a trip to the ER vs. Urgent Care to monetarily incentivize employees to make a more deliberate analysis of the situation. (As an aside, this is what “Consumer Driven Healthcare” is all about – getting patients more engaged in making smart healthcare decisions.)
Excessive ER usage therefore unnecessarily adds cost to the health plan. If an employer is self-insured, than they will feel the impact of this immediately. And if an employer is fully-funded, excessive ER expenditure will simply manifest itself in higher renewal rates, forcing the price of healthcare up for the employer, and ultimately, the employee.
Of course the impact to an employee doesn’t have to follow such a circuitous route: many insurance companies can deny payment of a claim if they feel the patient could have reasonably sought treatment elsewhere, rather than in the ER.
Getting To The Root Of The Problem
Employers don’t stand a chance in affecting change unless they take the time to understand the underlying root of the problem. In most cases we’ve encountered where an employer’s ER usage over indexes vs. the norm, it comes down to four main issues:
- Absence of Cost Disparity: The first issue, as you might image, is the lack of employee out-of-pocket cost disparity between care settings, the absence of which makes the key decision maker somewhat ambivalent, at least as far as the pocketbook is concerned. Work with your employee benefits advisor to design your health plans in such as way as to incentivize employees to make more educated healthcare decisions.
- Confusion Regarding Which Care Setting Is Most Appropriate: The second issue is a general lack of employee understanding of which care setting is most appropriate for which symptoms/illnesses. To that end we’ve included, at the end of this post, a long list of symptoms/illnesses grouped by setting. Work with your employee benefits broker or corporate communications team to build really great employee education communications around this information.
- Lack of UC Location and Hours of Operation Awareness: The third issue is a lack of knowledge regarding Urgent Care facilities. This includes nearby locations and hours of operation. Most of us know the exact location of the closet hospital and emergency room, and we all know that the ER is open 24/7. In absence of any other information, especially if we feel we are in a crisis or under duress, we tend to “go with what we know” and steer toward the ER. Work with your employee benefits consultant or internal communications team to create highly localized, geo-centric maps of nearby Urgent Care facilities – and go the extra mile by creating them not only for the office, but also customized to each employee’s neighborhood. Many carriers also offer geo-location Urgent Care directories as part of their mobile apps.
- Misperceptions About the Speed of Care: The fourth issue we encounter all the time is around a general misperception about the speed in which the person in need will receive care. As we all know, time is a critical factor when seeking medical attention. And its understandable to believe that the ER will provide care in the most expedient manner, but that’s only the case if the situation is life-or-limb-threatening. Emergency room nurses triage incoming patients based on the severity of their illness or injury. While an ER is required to attend to all patients, many find themselves waiting a very long time as other individuals with more urgent needs are treated first. In contrast, Urgent Care facilities serve patients in the order they arrive. The NIH study referenced earlier estimates an average wait time of less than 30 minutes in an Urgent Care center while emergency rooms average 2 hours and 15 minutes. Once again, work with your teams to help dispelled this popular misperception through well-crafted and frequent employee communications.
Like many people, your employees might be confused when it comes to making choices between all of the options available to them for same-day medical care. Distributing robust and highly localized educational materials is critical to driving an understanding of these options. We encourage you to use the information below in newsletters or email, or better yet, host special meetings to discuss various scenarios, so they know what to do and where to go.
Be sure also to thoroughly discuss company policies about injuries in the workplace, and be prepared to answer any questions about company insurance coverage for emergency care as well.
For more information on helping employees navigate their benefits, please contact us.
Addendum: Guidelines You Can Use In Your Communication Materials
Please note that the following text is simply for illustrative purposes. You, as an employer, should work closely with your employee benefits consultant, your HR department, your Medical Director and your insurance carriers to fully vet this information prior to publishing it for your workforce.
When a medical issue arises and you or a loved one needs care quickly, who should you call and where should you go? Is it a true emergency? Is this a 911, ER, or urgent care situation? Here are some guidelines to help you decide.
Life-or-Limb Care = Emergency Room
Emergency rooms stand ready to provide medical care at any time. However, the ER is meant for life-or-limb situations, not a bad cough or a sprained ankle. Here are some conditions that should always be treated as emergencies:
- Chest pain that is sudden and/or persistent and radiates to your arm or jaw or is accompanied by sweating or shortness of breath
- Unexplained shortness of breath or wheezing
- Severe pain, particularly in the abdomen or starting halfway down the back
- Sudden, unexplained vertigo or fainting
- Difficulty speaking, altered mental status or confusion, especially with a noticeable droop to one side of the face
- Newborn baby with a fever
- Intestinal bleeding (shows as red or black blood in stools or clots)
- Falls with injury or while taking blood thinning medications
- Broken bones or dislocated joints
- High fevers (over 103.5) or fevers with rash
- Bleeding that won’t stop or a large open wound, especially on the face or head
- Vaginal bleeding or unexplained fluids with pregnancy
- Serious burns
- Any seizure without a previous diagnosis of epilepsy
When to Call 911
There may be situations when driving yourself or a loved one to the hospital won't get you the medical care you need fast enough.
- When a heart attack or stroke is suspected, taking an ambulance is safer as trained paramedics can deliver life-saving care en-route.
- Never try to drive yourself with severe chest pain, severe bleeding, any vision impairment, or if you have fainted or had a seizure. You risk putting yourself and others in great danger if you pass out or lose control at the wheel.
- 911 is also the best option for dealing with severe injuries that involve bleeding, an unresponsive person (especially infants), anytime a person has stopped breathing and requires CPR, or in the case of drowning — even if the victim has started breathing and is responsive. Call 911 right away for any of these emergencies — it's better to be safe than sorry.
The National Center for Health Statistics discovered that 48 percent of ER patients who were seen but not admitted to the hospital visited the ER because their doctor's office was not open. This causes congestion in many emergency rooms and can delay life-saving care to those who are in true emergency situations.
If you are unable to get a same-day appointment with your doctor, but have a medical condition that doesn't warrant true emergency care, urgent care facilities are the best option. Urgent care departments are same-day clinics that don't require an appointment, but you will still probably have a wait time — again, however, almost always 30 minutes or less.
Some symptoms that can be treated at an urgent care facility if your regular doctor is unavailable include:
- Fever without rash
- Sprains, strains, and other minor trauma
- Painful or difficult urination
- Persistent diarrhea (if there is blood or black clots present, you might get sent to the ER)
- Severe sore throat or severe flu-like symptoms
- Persistent vomiting or suspected food poisoning
Be prepared whether you are heading to the emergency department, urgent care, or taking a ride in an ambulance. Have a list of any medical conditions, medications, allergies, and any surgeries in your wallet or pocketbook along with your insurance card. Make sure to pull it out if possible or alert a medical caregiver to its location. The more information you can give, the more accurate and speedy a diagnosis can be.