Avoidable emergency room (ER) visits are a critical component to cost effective population management. Frequent and potentially avoidable use of hospital ERs is extremely costly, especially when care may be able to be provided in a less expensive setting.
In a patient centered medical home (PCMH) reporting project performed by Milliman, ER utilization was one of several utilization targets. Specific to ER utilization, several measures were identified to allow for a broad understanding of the characteristics of those visiting the ER. These measures compared the pre PCMH enrollment period as well as the post PCMH enrollment period. Also included in the analysis were member details such as age, diagnosis, and dates of visits. Milliman performed drill-down analysis to identify opportunities for cost reduction, such as those members who visit the ER frequently (e.g. 3 or more visits within 4 months). The analysis also provided insight into access and care management issues using the day of the week the ER visits were occurring.
While evaluating the characteristics of the ER population, integrating it with potentially avoidable ED visits can be accomplished using different methodologies. In this project, the New York University (NYU) algorithm of potentially avoidable ER visits was used.
From the claims data, this algorithm uses the diagnosis of patients of those who visited the emergency department and categorizes them into defined categories. The primary categories that address the potentially avoidable ED visits are:
- Primary Care Treatable
All ED visits for primary diagnosis of injury, mental health problems, alcohol, or substance abuse are also classified into separate categories but will not be addressed within this blog post. Please see the links below for additional detail.
Another option for identifying avoidable ER visits is to evaluate the diagnosis codes against those diagnoses identified as Avoidable Visit diagnosis codes by the MediCal Managed Care Division. Please see the link below for more detail.
- New York University Roger F. Wagner School of Public Service
- The Commonwealth Fund
Watch the Milliman Healthcare Analytics Blog for upcoming posts:
- Shifting the focus to non-urgent visits to impact cost savings – Annals of Emergency Medicine – Avoidable Admissions from the ER