More than two-thirds of the 6.5 million emergency room visits for people under age 65 are avoidable, according to a study released today by Truven Health Analytics. The study examined insurance claims data for over 6.5 million emergency department visits made in calendar year 2010 and found that just 29% of patients required immediate attention in the emergency room.

About 72% of emergency room visits made by patients with employer-sponsored insurance coverage are for causes that do not require immediate attention in the emergency room, or are preventable with proper outpatient care:

  • 24% did not require immediate attention
  • 42% received care that could have safely been provided in a primary care setting
  • 6% received care that would have been preventable or avoidable with proper primary care.

The analysis surmises that diverting just 10% of these unnecessary visits to an office setting would result in a net savings of $18.68 in total allowed costs per health plan member, per year.  Based on the 24 million enrollees represented in the Truven Health MarketScan databases, this represents a total potential savings of $461 million each year.
Based on clinical records and the patient’s primary diagnosis, Truven gave all visits probabilities of falling into four categories:

1. Nonemergent – medical care was not required within 12 hours.
2. Emergent/primary care treatable – medical care was required within 12 hours, but it could have been safely provided in a primary care setting.
3. Emergent (preventable/avoidable) – medical care was required within 12 hours, but could have been dodged with timely and effective outpatient care.
4. Emergent (not preventable or avoidable) – medical care was required within 12 hours at the emergency room. 

A diagnosis of “abdominal pain unspecified site” is given a 67% probability of second category and a 33% probability of the fourth. Truven’s report says this method was used to acknowledge the “gray areas” of claims and diagnosis.

“That is, it recognizes the fact that, based on the diagnosis information on an ED claim, it is impossible to say with certainty that ‘X’ visit was not necessary, only that ‘Y percent’ of the time it has been shown to be unnecessary,” the report reads.

Across six broad health plan types, the percentage of nonemergent visits differed only by 2.6% and of Category 4 visits by 2.5%. More substantial differences were seen by gender: Women (who accounted for 17% more ED visits overall), were more likely to make Category 1 visits and less likely to make Category 4 visits than men.

Striking variations were also seen by age – more than 75% of patients age four and under were in the ER for Category 1 or 2 visits. The second largest age group for these most-avoidable ED trips was those in the 20-29 range.

“For the youngest patients, the rate may reflect overly anxious parental behavior and suggests an educational opportunity,” says the report. “It may also reflect an underlying shortage of available after-hours pediatric care. The peak observed in the young adult population is most likely a reflection of the lack of established primary care relationships and care access difficulties for a younger working population.

“Given the extremely high cost of ED care versus care in alternative settings, the impact of any program that shifts even a small percentage of care by helping this population establish appropriate care relationships and providing better access to the appropriate treatment setting will pay large dividends.”

In 2010, the average ED visit cost $1,316 and the average office visit cost $145, so the net saving of every emergency visit replaced with a trip to primary care would have been $1,171.

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