THE CHALLENGE:

REDUCE POTENTIALLY AVOIDABLE EMERGENCY DEPARTMENT USE

While Massachusetts continues to be the national leader in access to high quality health care, it is among the most expensive states in the country, ranking 2nd overall in per capita health care costs. A significant contributor to this is the unnecessary use of expensive hospital settings. A recent Commonwealth Fund Scorecard on State Health System Performance identified avoidable hospital use and costs as key areas for improvement, ranking the state’s performance below the national average with a worsening trend over time, despite giving high marks to Massachusetts overall.

1 in 3 ED visits
are potentially avoidable

Potentially avoidable ED use is a particularly strong area for coordinated action. Potentially avoidable ED visits are those that are preventable or inappropriate. According to the 2017 Massachusetts Health Insurance Survey, they account for nearly one million visits each year, or over 1/3 of total ED visits. Potentially avoidable ED visits are prevalent for members of all types of health insurance, with commercially insured members accounting for nearly 1/3 of the total. Upper respiratory infections, skin rashes, allergies, and back pain are among the most common conditions for which Massachusetts patients seek care in the ED unnecessarily.

ED visits can be 5x more expensive than primary care or urgent care visits

The cost of an ED visit can be five times more expensive than the cost of care provided in a primary care or urgent care setting. The Massachusetts Health Policy Commission conservatively estimates that, across the state, the annual cost is $300-350 million on avoidable ED visits for commercially insured members alone. These visits also contribute to spending in the state’s Medicaid program, and reducing avoidable ED use is a key goal of MassHealth’s new Accountable Care Organization (ACO) program.

Of course, not all ED use is avoidable. Much is necessary, appropriate, and in many cases life-saving. However, providers and payers broadly agree that shifting ED use for non-urgent health problems to more appropriate settings will relieve crowded EDs, improve quality and patient experience, and lower the cost of care.

THE MOST COMMON CONDITIONS FOR WHICH PEOPLE HAD AN AVOIDABLE ED VISIT WERE:

  • Sinusitis

  • Stomach Pain

  • Rashes and skin conditions

  • Acid reflux

  • Bronchitis

  • Dental pain

  • Back pain

  • Allergies

  • Urinary tract infections

  • Ear and eye infections

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