Cheaper Isn’t Always Better

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 twenty 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 fifty 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 visit. The authors thus predicted that 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 cares 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.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. This review was written by Michael Rushton, DO. Dr. Rushton is currently a third year resident in Emergency Medicine at Spectrum Health/Michigan State University. 

Abstract

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 thirty-seven 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

Wang B, et al. Health Affairs. 2021; 40 (4): 587-595.