A leading medical organization opposes one high-profile insurer initiative to discourage non-emergent ED use, but does not plan to contest the program in a legislative or legal context.

Nov. 10—Emergency department (ED) use has spiked in recent years, leading to divergent responses from insurers.

Although previous research in various states or groups of states has found conflicting evidence about whether ED use increased following the Affordable Care Act’s (ACA’s) coverage expansion, new federal data conclusively shows a significant surge.

Recently released counts from the Agency for Healthcare Research and Quality (AHRQ) found that total ED visits increased by 3.4 million, to 131.6 million, in 2014—the first year of ACA’s coverage expansion. That compared to an increase of 900,000 the previous year.

Recent counts from the Centers for Disease Control and Prevention (CDC) found an even larger 2014 increase of 11 million, to 141.4 million total visits, based on an analysis of 2014 and 2013 data. That compared with a 517,000 increase the previous year, according to 2012 data.

The CDC also found that the 2014 increase was fueled by Medicaid. ED visits by beneficiaries in Medicaid and the Children’s Health Insurance Program increased by 25 percent, or more than 10 million, that year. That increase vastly outstripped a decline of 2.9 million in visits by the uninsured.

Medicaid enrollees also drove the 2014 increase in the AHRQ count, with an increase of 6 million visits.

“Given the prior research, it’s certainly plausible that ER use went up from the ACA,” Benjamin Sommers, MD, PhD, associate professor of health policy and economics at the Harvard T. H. Chan School of Public Health, said in reference to the new data.

Sommers said most of the ED surge among Medicaid enrollees appears to be by people who were previously uninsured and now have coverage.

“That has an enormous benefit to these families, in terms of financial protection against the often extremely high cost of ED care,” Sommers said in an interview.

But the increase also represents an influx of patients into the costliest care setting, which is frequently covered by either Medicaid managed care plans or commercial insurers. Those enrolled in private insurance had smaller increases in utilization.

Although some health policy observers have theorized that the initial surge in ED use would subside after pent up demand was addressed under the ACA coverage expansion, ratings agency reports tracking hospital utilization have found ED visits further increased in 2015 and 2016.

Insurer Initiatives

The national 2014 increase in ED visits echoed a 20 percent increase that Anthem said it saw among enrollees. “A large percentage of those visits were for nonemergency ailments,” Gene Rodriguez, director of public relations for Anthem Inc., said.

“Our current effort to decrease inappropriate use of the emergency room is timely given our work over the past few years to improve access to care for nonemergency conditions and the increase we are seeing in the inappropriate use of the emergency room,” said Rodriguez.

Anthem has told customers in Kentucky that if they go to the ED for non-emergent care, they may have to cover the entire cost on their own.

The nation's second-largest insurer, Anthem has urged patients to consider alternatives such as urgent care centers, pharmacies, nurse advice hotlines, and telemedicine. The strategy is an escalation from the practice of increasing ED copayments to try to deter unnecessary visits.

Anthem’s push in Kentucky, which began in 2015, will expand to Indiana next year and possibly other states that have seen an increase in unnecessary visits.

David Anderson, president and CEO of BlueCross BlueShield of Western New York, said in an interview that he also has seen an increase in ED use among his Medicaid population.

“We haven’t gone to the type of policy that Anthem has gone to yet, and I would not say that is important for me,” Anderson said. 

Excessive ED use does not even make the top ten on Anderson’s list of priorities, which is topped by efforts to transform his local delivery system to become more value-based.

But ED use plays a critical role even in that area, with the ability to reduce ED visits emerging as an indicator of whether Medicare Shared Savings Program accountable care organizations (ACOs) were able to achieve shared savings in 2016, according to recent data from the Centers for Medicare & Medicaid Services (CMS). The lowest performing ACOs had a 2.2 percent increase in ED visits that year, compared with a 3.8 percent decrease for the best-performing ACOs.

Arkansas Blue Cross and Blue Shield also saw ED use increase for the first couple years after the state expanded Medicaid under the ACA, said Curtis Barnett, president and CEO.

“That was the place where they were used to receiving care, and so we certainly saw a pretty high utilization,” Barnett said in an interview.

However, the insurer has begun to see that utilization “flatten and maybe even [have] a slight decrease over this last year,” he said.

Barnett credits the improvement to an initiative that the insurer launched a couple years ago to attribute all of its enrollees to a primary care physician “whether they have had an encounter or not, because we wanted that outreach to occur to get them into the healthcare system in the appropriate ways.”

“We even did that with our Medicaid expansion population, who are much more prone to use the emergency room than other populations,” Barnett added. “We’re trying to put people together with a patient-centered medical home and try to use that as a way to seek care, rather than going to the emergency room.”

In addition, the insurer has been reaching out to the Medicaid population to increase health literacy and “help them understand this is how you approach and navigate the healthcare system,” Barnett said.

Surge Responses

Others also have reacted to the ED use surge.

Rep. Diane Black (R-Tenn.) said in an Oct. 13 interview on MSNBC, “I would get rid of a law that says that you are not allowed, as a healthcare professional, to make that decision about whether someone can be appropriately treated the next day, or at a walk-in clinic, or at their doctor.”

Black’s office did not respond to emails about whether she plans legislation to amend the Emergency Medical Treatment & Labor Act (EMTALA). Hospital advocates said they did not view the comment as a serious proposal.

Ryan Stanton, MD, an emergency physician in Lexington, Ky., and a spokesman for the American College of Emergency Physicians (ACEP), also doubted a change to EMTALA is likely.

“I understand that she’s saying we have to do something to alter the way that we utilize the U.S. healthcare system, but going after EMTALA, which is directly designed to protect those at highest risk by guaranteeing stabilizing health care at any ED around the country, is not the way to do it,” Stanton said in an interview.

Stanton criticized the Anthem initiative to reduce unnecessary ED use as “just a way for them to pad profits.”

Although “the volume in the emergency departments just continues to grow year after year after year,” Stanton said, “it’s the access point for many people in the healthcare system and for many people it’s the only access they’ve got.”

Stanton said Anthem’s new policy appears to violate the “prudent layperson” standard enshrined in federal and many state laws, which say that if a reasonable layperson feels like they are having an emergency, they have the right to seek emergency care and it would be covered by their insurance company.

He said several GOP healthcare reform proposals this year also would have removed the mandatory requirements regarding ED assessments, which was why ACEP opposed those bills.

However, his group lacks the political clout to push legislation explicitly barring the Anthem approach or to push the government to enforce the “prudent layperson” standard, he said.

Stanton predicted that action against policies that reduce access to EDs will come from another direction.

“They’re going to deter someone from going to the ER, there’s going to be something bad that’s going to happen, there’s going to be lawsuits, and then there are going to be things that change,” Stanton said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, November 10, 2017