Strategies to Manage Unnecessary ED Claims and Costs

By Arnel Mondejar

Today, brokers are aware that unnecessary use of emergency departments (EDs) can significantly impact healthcare spending for their employer group customers.

In 2016, there were 145.6 million ED visits in the United States – a 20% increase in just 10 years. From our data and experience, employer groups vary tremendously in their ED usage, and unnecessary ED visits might account for 25 to 35% of their total healthcare spend. Many of these cases could have been addressed at a lower level of care, such as with a primary care physician, urgent care center, or telemedicine option. Even with available alternatives, unnecessary ED visits have been on the rise.

Here are the driving factors causing brokers and their employer groups to work together with health plans, plan administrators, provider networks and employees to try to reduce this trend:

  • High Costs. The ED is expensive. The average cost of a visit is about $2,200—10 times more than care at an urgent care center for the same diagnosis. Seeking ED alternatives can translate into lower out-of-pocket expenses for plan members and tremendous savings for the employer group. In total, a mid-sized group might save hundreds of thousands of dollars, and a large group, millions.
  • Long Wait Times. In the ED, issues are addressed according to severity, so patients with non-emergent conditions must wait to be seen after those who have critical medical concerns. In California, wait times can often last more than five hours. Needless to say, non-emergent patients will actually have a much better experience at a lower level of care – in most cases, waiting less than 30 minutes to be seen.
  • Adverse Outcomes. Misuse of the ED can have an adverse effect on long-term outcomes. For example, about half of all patients who leave the ED do not have the follow-up care that’s needed to help get to the root of their medical issues. This can cause adverse effects to that person’s health and may even lead to a return to the ED.

Strategies to Reduce Unnecessary ED Visits

Brokers should be aware of the following strategies and tools available so they can advise employers on how they can reduce unnecessary ED visits:

  1. Data analytics to identify ED super-utilizers.

Data analytics is a vital tool for effective ED management. Brokers should ensure their groups have access to sophisticated data analytics. In this way, they can receive insights into their plan’s overall ED utilization trends. For example, brokers can suggest groups request a report from their plan to identify super-utilizers who have visited the ED three or more times in the past 12 months. Or, groups can have their plan configure a real-time dashboard to monitor ED usage and costs, so they can promptly take action to minimize both factors.

  1. Communicate with members to identify gaps in care.

Once identified, super-utilizers should be targeted for education. For example, be sure health plans have an outreach program to contact super-utilizers to find out why they went to the ED. These conversations might reveal a gap in care. For example, the network might be lacking primary care physicians (PCPs) within a convenient distance to the member’s home or work. Make sure plans can help groups address such gaps by recruiting PCPs or providing other options, such as urgent care, walk-in clinics, or telemedicine.

  1. Ensure appropriate follow-up care with primary care physicians.

ED physicians only have time to address the primary concern that brought members into their facility. For example, if a member has a urinary tract infection, the ED physician might prescribe an antibiotic, but they aren’t in a position to provide holistic care—that’s the role of the PCP.

Brokers and their groups should ensure that a plan’s outreach program also engages with ED utilizers to schedule follow-up care with PCPs, when needed. PCPs can perform a full assessment that takes into account all risk factors such as existing conditions, vital health statistics, and family history. By collecting comprehensive health information, the PCP can address a member’s overall health, instead of just a single health issue.

The PCP can also educate members on health practices to keep them from going back to the ED. Furthermore, a PCP, working with the plan, could suggest members enroll in disease management programs, if they have chronic conditions, such as diabetes or high blood pressure, that cause them to frequent the ED.

  1. Educate members on the various levels of care and what types of conditions are appropriate for each.

Brokers should ensure groups are providing educational material to plan members. This material should breakdown common medical issues that can be addressed at the various levels of care – including PCP, urgent care, ED, and telemedicine. Through education, members will come to understand that ED management can help reduce their out-of-pocket costs, while also fostering quality care and a superior patient experience.

Educational material must also include contact information for the plan’s service center, so members can call if they need help finding a provider at an appropriate level of care. Digital resources, such as an online portal with the option to chat with service agents, can also be helpful. With today’s multi-generational workforce, it’s useful to have both paper and digital resources to help identify ED alternatives.

Education can also occur via member outreach. For example, one group in manufacturing implemented an internal clinic to help rein in ED costs. At first, the in-house clinic was under-utilized. Through member outreach, the group learned that plan members were avoiding the clinic because they believed supervisors would find out about their medical issues. The plan educated members on their right to privacy in all venues of care. Once this misconception was dispelled, the manufacturer saw an increase in clinic utilization and a reduction in ED costs from 25% to 12 % of their total spend.

  1. Utilize ongoing monitoring to combat unnecessary ED visits into the future.

To minimize ED visits into the future, brokers must ensure groups have access to ongoing monitoring. Armed with up-to-date insights, groups and plans can work together to address emerging issues. For example, the member outreach program might identify ongoing super-utilizers and enroll them in the plan’s case management program. This would allow case managers to closely guide those members to appropriate levels of care, even helping to schedule appointments with appropriate providers.

If a group launches a new ED management initiative, monitoring tools also provide a baseline for comparison. Several months to a year down the line, groups can determine if the initiatives have made an impact. Monitoring can enable groups to promptly address any unexpected spikes in ED utilization.

However, if unnecessary ED visits continue to be a challenge, brokers might consider organizing a summit for a group, which would include the plan administrator and other service providers, to recalibrate its ED management approach.


Arnel Mondejar, RN, BSN, CCM is the vice president of care management at HealthComp, a benefits administrator for self-funded health plans. Mondejar oversees HealthComp’s care management department, which helps brokers and employers control healthcare costs by improving health outcomes. This department provides services such as utilization review, case management, disease management, prenatal programs and targeted programs for cancer and ER visits.