Pursuing solutions to emergency room misuse

One might call it a symptom of the broken health care system: emergency room misuse. This happens when patients turn to the emergency room for care without experiencing a serious or life-threatening emergency. While not a new phenomenon, it’s quickly becoming a hot-button issue with providers and payers alike, and one that is prompting more questions than answers. (Although Gravie is pursuing a promising solution; more on that in a bit.)

Emergency room – or emergency department – misuse has been in the news recently as UnitedHealthcare among others have announced new policies to retroactively deny emergency room claims, with a backlash from provider groups that expressed concern that such measures would discourage people from seeking care. The pushback ultimately led to UnitedHealthcare hitting pause on the policy.

This is just one example of issues surrounding a growing trend: people visiting the ER who are seeking care for non-emergency conditions. These non-emergency visits are a strain on the emergency department staff and resources – no small issue as providers struggle to also treat the true life-or-death medical conditions coming through their doors every day. For payers, these non-emergency ER visits drive up costs. While no one wants to discourage people from seeking care, there’s no denying it’s a complicated, expensive issue for the system as a whole.

What’s driving this trend? There are a few key factors, including rising health care costs and a lack of affordable preventive care services that help individuals catch ailments before they escalate into health issues; gaps in coverage and confusing pricing and policies if one has health insurance; and a lack of education around what warrants a visit to the ER and what alternative care options exist for issues and incidents that can be treated elsewhere.

It’s certainly a complex issue and one of the driving factors that led to the creation of Comfort, the nation’s first-of-its-kind health plan that provides zero-deductible, zero-copay, and 100% coverage on most common healthcare services, at a cost comparable to traditional group health plans. This approach offers a new take on the issue of emergency department misuse – and it’s not simply just an idea, it’s a plan that’s been in practice for the past year and has already seen promising results.

Comfort offers a solution to the ER misuse problem, not by limiting emergency room care like others have attempted, but by drastically restructuring health benefits to motivate individuals to access preventive care, keep up with their medications, and seek ER alternatives, such as urgent care, when it will suffice. Our no-cost services guide includes many tests and services that one might traditionally think warrant an ER visit or might put off for fear it may come with a high out-of-pocket cost. Has this radical rethinking of coverage helped reduce ER visits?

The proof is in the pudding. One of Gravie’s largest customers on the Comfort plan was able to reduce health benefit costs by 16%, even while covering more services (this customer has saved a total of 36% on health benefits since making the switch to Gravie in 2017.) Trips to the emergency room went down by 80%, and instead, individuals utilized urgent care clinics or their primary care doctor to resolve their issues. This shift in behavior was influenced by Gravie covering, and therefore incenting, individuals to get the care that they needed, as soon as they needed it, not waiting for or encouraging an “emergency only” mentality. This same customer was able to see an increase in the number of insured employees by 12% as many employees opted back into health benefits knowing they didn’t have to meet a deductible before accessing care. And they reported improved health outcomes for employeeswho are no longer deterred from or second guessing going to the doctor in a timely manner.

Measures such as retroactively denying emergency room claims discourage people from seeking out care, which means we have to find a better way. With Comfort, we’re improving the healthcare experience for all involved by promoting smarter healthcare engagement and better outcomes.