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Emergency Measures

With more people reporting to costly emergency rooms for nonemergent care, employers are looking for ways to help employees rethink their ER visits.

Thursday, March 1, 2012
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If you feel as if an elephant's sitting on your chest, you'll hopefully recognize the signs of a heart attack and get to the emergency room stat.

And if you wake up with sniffles, you'll most likely drag yourself in to work, maybe picking up some medicine on the way.

But not every ache and pain is that easy to diagnose at home. When is a stomach ache, a blinding headache or a 101-degree temperature an annoyance, and when is it a true emergency?

As it is, thousands of anxious Americans -- uncertain about what their symptoms really mean -- don't make a doctor's appointment to find out. Instead, they rush to the hospital emergency room, where they'll sit for hours, talk to a parade of professionals and maybe undergo some tests to learn they could have waited to see their own doctor. And the cost for that ER visit is often paid for by their employer's health plan.

Indeed, unnecessary emergency room visits are ratcheting up healthcare costs for U.S. businesses already struggling with rising medical premiums and bills. That's why more HR leaders are steering employees away from the ER. They are exploring options -- from urgent-care centers to on-call health providers to telehealth services -- that are more convenient and far less costly for them and their employees.

In fact, in five years, it will be unusual for a company not to provide an expedient alternative to ER visits, says Jonathan Linkous, CEO of the Washington-based American Telemedicine Association.

Right now, there is no question that ER visits are growing. According to the U.S. Government Accountability Office, ER visits increased by 11 percent from 1997 to 2007; in 2007, about 117 million people visited the ER, and 8 percent of the visits were nonemergent.

In a letter to a Senate health committee in April 2011, the GAO predicted that the use of emergency departments, "including use for nonurgent conditions, may increase as more people obtain health-insurance coverage as the provisions of the Patient Protection and Affordable Care Act are implemented.

But there is debate as to whether many of those nonemergent cases could be handled just as well, and at far less cost, in another facility, such as an urgent-care center or retail clinic.

In a 2010 study by the Rand Corp., researchers suggested that 16.8 percent of all visits to the hospital ER could be treated at a retail medical clinic or urgent-care center, at a savings of $4.4 billion annually in healthcare costs. Conditions such as minor acute illnesses, strains and fractures could be safely treated outside hospitals, according to the study, although it added that more research is needed to ensure that equivalent care is provided.

"Patient traffic to hospital emergency departments has been growing, but a significant proportion of patients could be safely treated in these alternative settings," says lead author Robin Weinick, a senior social scientist at Rand, a Santa Monica, Calif.-based nonprofit research organization. "Diverting these patients to alternatives such as retail clinics and urgent-care centers could shorten their waiting times and save money."

Certainly, "no one should go for a cold or even the flu unless they are compromised," as with HIV, says Helen Darling, president and CEO of the Washington-based National Business Group on Health. "I would say equally as important as steering people from the ER [to control] cost is [steering them away to promote] safety" from the risk of infection.

Many consumers, however, feel they have no choice because doctors' offices are often closed during nights and weekends. What's more, availability is affected by a growing shortage of doctors, especially in pediatrics and internal medicine, Darling says.

Astute HR leaders are on top of the statistics. Over a year ago, Elaine Britt, director of benefits for Rice University in Houston, was informed by her consultant, The Advisory Board Co., that employees' ER visits over a two-year period were 12 percent higher than the national benchmark and cost an average of $1,400 per visit.

"When we combed over claims information, we discovered that the cost in emergency department procedures was increasing 30 percent to 40 percent for Rice University," says Edward Przezdecki, a consultant with the Advisory Board, a Washington-based performance-technology company that analyses claims data.

"We noted there were a lot of people using the ER for relatively minor things, not just on the weekend, even during the day," says Britt. "We look at trends. . . . Some things you can't control, but some things can be taught, through wellness-plan design, even education."

Breaking the ER Habit

Rice employees are now encouraged to visit freestanding urgent-care centers, designed to diagnose and treat minor conditions on a walk-in basis.

"If you have a high fever, they may not want to see you. But if you have an earache on the weekend and it's not manageable with over-the-counter medication, you may want to go to an [urgent care] center and get care," Britt says.

Breaking the ER habit required a two-pronged strategy. The first was economic: Rice raised the ER co-pay from $75 to $150 and set the co-pay for urgent-care centers at $50; the co-pay for a primary care physician is $25. Britt asked the university's insurer, Aetna, to add more care centers to the HMO network.

"In our recent experience, $150 is coming closer to the new norm. Some organizations are as high as $350. There is a definite upward trend in the emergency department co-pay. ... It reflects a desire to steer [employees] from the [emergency department], and the growing cost of the ED as well," says Matthew Cinque, a managing director at the Advisory Board.

The second prong for breaking the ER habit was education: Rice launched a campaign to raise awareness of urgent-care centers, including personal letters, internal communications and refrigerator magnets for the home.

The strategy has worked. In only a year, ER visits are down 12 percent. Emergency procedure costs were down $103,000 in the first six months, and the university should save a little over $200,000 for 2011.

"We really believe a lot of this was purely an educational effort," Britt says. "We ran it by the legal area. We're not trying to give medical advice. ... We're trying to get people to understand it's our behavior driving part of the cost. If there are ways we can become better shoppers, that saves us all money down the road."

The urgent-care center "is really a toned-down emergency room and costs significantly less. ... Most of our benefits are designed to drive people there," says Dr. Michael Cryer, senior vice president and medical director with Aon Hewitt in Houston. The ER co-pay for most Aon Hewitt clients is about $200; the urgent-care-center co-pay is about $50.

There are more than 9,000 urgent-care centers in the United States, and that number has been growing by 300 a year since 2008, the first year benchmarking was done, according to Laura Gaskill, communications director for the Urgent Care Association of America in Warrenville, Ill. Some employers are growing creative in their search for ways to divert employees from the ER to such centers.

One obvious alternative is a 24/7 health-advice line, which may be offered through a major health plan. Some businesses and associations are adopting the "concierge" model of health services, contracting with a physician to cover all calls for a flat fee.

The American Telemedicine Association has a contract with DocTalker Family Medicine, a Washington-area service that provides 24/7 physician consultations by phone, email and even house calls. An annual fee covers a certain number of consultation hours for its 12 employees, who also have a traditional health plan.

"Almost every employee uses it. It's reduced overall costs of insurance. ... The house call is back," says Linkous.

One company that takes that literally is WhiteGlove Health Inc., based in Austin, Texas, which contracts with more than 400 self-insured employer groups in several states. Nurse practitioners treat members at home, the office or hotels, seven days a week, 8 a.m. to 8 p.m. For $25 per person per month, WhiteGlove provides acute care, diagnostics and wellness; chronic-care services start at $35 per month.

How do ERs perceive this push?

The American College of Emergency Physicians based in Washington cautions against a rush to anti-ER judgment, saying emergency rooms provide a critical service not duplicated by urgent-care centers.

"Even in the ER, in the course of the workup, [physicians] may find an underlying problem that is more critical than might appear on the surface," says Dr. Richard Turner, a member of the ACEP public-relations committee. "Urgent-care centers would not be ready to deal with those occurrences." What's more, he adds, if an urgent-care center does find a more serious problem, transfer to an ER may delay treatment.

"The need to reduce healthcare costs is clear, but policymakers are looking in the wrong place if they take aim at emergency departments," says Dr. David Seaberg, ACEP president. "Preventing emergency visits will not put a significant dent in the nation's soaring healthcare costs." While ER visits rose to 136 million in 2009, emergency care represents only 1.9 percent of the nation's total health care dollar, according to ACEP.

The Telehealth Trend

Urgent and emergency care aside, there's little doubt that the future of on-the-spot healthcare lies with telemedicine -- the ability to consult with a physician via the computer or wireless phone.

In fact, it's surprising that, while physicians have been videoconferencing for years, only two companies in the United States and one in Great Britain provide a contract service for employees, according to Linkous.

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One of those is Teladoc, based in Dallas. Founded in 2002, Teladoc contracts with companies to provide 24/7 videoconferencing or telephone consults with board-certified physicians.

Teladoc has been an ideal fit for Plano, Texas-based Rent-A-Center. RAC has 19,500 employees in 3,000 locations in North America, with about 12,000 of them enrolled in its medical plan. Not only has Teladoc helped the firm cut unnecessary ER visits, but it provides access to emergency care for employees in remote geographic areas.

"In Dallas or Philadelphia, there's an urgent-care center on every corner; you can just drive there. . . . We have a lot of facilities in rural locations. It makes really good sense," says Steven Spratt, RAC senior director of compensation and benefits in Plano, Texas.

The consult costs employees nothing; Teladoc charges RAC $38 per consult, plus a monthly administrative fee of about $1 per employee.

It's paid off. ER visits in October were down 6.3 percent from the previous year, and about one-quarter of enrolled members are using the program. The company saved $300,000 in the first five months of 2011, with projected savings for the year of $718,654.

Patients consult with board-certified physicians who are licensed in the patient's state so they can prescribe medication. Patients are called back within 22 minutes, and the average visit is 10 minutes. Teladoc also maintains an electronic health record on all participants.

"Telehealth has been practiced for generations by doctors doing after-hour coverage for each other -- a call from a mom with a sick child, a weekend cough that won't go away," says Teladoc CEO Jason Gorevic, adding that he's pleased corporate clients report about 15-percent use of the telehealth service. "We reduce ER utilization," he says. Some employers also report improved productivity in terms of work hours saved.

"Some of our [Aon Hewitt] clients swear by [telehealth], especially the busy executive," says Cryer. "I 100-percent believe you'll see more e-medicine. If you're my patient, I'll treat you frequently by phone. It's a sign of the future, and it's good thinking."

Cryer does, however, advise companies to weigh the cost/benefit of a "value-added" service such as teleconferencing, to make sure that the savings in ER visits make up for the added cost to the health program in terms of administrative fees. Urgent-care centers are more commonly offered as healthcare options by employers than is telehealth because they are part of the health-plan network, although Cryer predicts that, ultimately, teleconferencing, too, will be integrated into a network.

That time is approaching. Experts agree that electronic videoconferencing will one day be a familiar part of healthcare delivery in the United States. The main reason, of course, is the inexorable progress in computer and cell-phone technology.

"It's amazingly easy [to use]," says Linkous. On the computer, there is easy access to services like Skype, and most computers today are equipped with camera, microphone and speakers. New cell phones allow teleconferencing by phone, and a wireless network allows face time at no additional cost.

Teleconferencing also fits perfectly into the newest model in healthcare delivery -- the "integrated delivery network."

One of the chief examples of the integrated delivery network is the accountable-care organization. An ACO is a network of doctors and hospitals that is paid to keep people well by tracking the progress of groups of patients and providing incentive bonuses based on certain measures of success. ACOs have gotten a big boost in the federal Patient Protection and Affordable Care Act, which allows them to contract with Medicare in 2012.

One of the first goals of integrated delivery networks will be to offer an alternative to high-cost ER services, says Cryer.

"There's some significant change coming. The services that [Teladoc and others] are marketing could become part of an integrated delivery product. ... [T]hese integrated networks will be looking for ways to improve their ability to monitor, support and react to their patients' wellness and medical needs," says Cryer. "This could take the form of extended office hours, urgent-care services, telemedicine support and possibly even home visits with physician extenders."

"There is a trend toward rewarding providers for reducing ED utilizations," agrees Cinque.

"Many of the new programs that insurance providers are launching are getting doctors to take more responsibility for reducing costs by shifting the risk to the [doctrs and hospitals]," he says. "In some scenarios, pay-for-performance is linked to patient outcomes. .. . One such outcome is a reduction of ED utilizations. Doctors could have incentives to reduce hospital visits in certain populations. We're seeing expanded hours and more access to the physician's office."

What's holding up telehealth is not technology but licensure laws, says Linkous. For example, some states do not allow physicians to prescribe medication based on an audio examination.

"Despite that, these things are moving forward very rapidly," says Linkous. "The technology is pretty easy [and] user-friendly. ... Doctors are getting used to it. We're developing practice guidelines, so we're assured of some consistency."

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