ACA Will Increase ED Visits: Can Call Centers Ensure This Doesn’t Happen?

By Mark Dwyer

One of the greatest fallacies of the Patient Protection and Accountable Care Act (PPACA) is thinking that assigning 32 million uninsured Americans to an independent or state run insurance plan will reduce the number of ED visits. This isn’t going to happen for a number of reasons.

First, these previously uninsured patients, despite now having insurance coverage, will find themselves in plans with insufficient primary care physicians (PCPs) willing to accept them due to full practices or an unwillingness to add patients with Medicaid’s reduced reimbursement rates. Unable to attain timely care, these patients will return to their comfort zone, the ED, in an attempt to receive treatment within hours instead of days, weeks, or months.

Further increasing the patient’s use of the ED is the current Emergency Medical Treatment and Active Labor Act (EMTALA) mandate that assures anyone who presents to the ED access to medical evaluation and emergent treatment, regardless of ability to pay. A recent National Ambulatory Medical Care Survey found that 4.5% of patients presenting at the ED were triaged as needing immediate evaluation, 11.3% emergent, 38.5% urgent, and 29% semi-urgent or non-urgent (defined as needing to be seen within 1-2 hours or later).

Does this provide an opportunity for the call center to play a role? Is it possible for the call center to safely triage select patients of this 29% semi- or non-urgent population to alternative, less-costly delivery locations? If so, it is estimated that avoiding hospitalizations for conditions treatable in ambulatory care settings could save the U.S. healthcare system $30.8 billion annually.

But, at what point must this redirection take place? According to the American College of Emergency Physician’s (ACEP’s) policy on medical screening of emergency department patients, the ACEP strongly opposes deferral of care for any patients presenting to the ED. The ACEP’s policy goes on to say that in cases where deferral is necessary, the hospital must have policies in place to ensure the patient has access to an alternative setting for timely, appropriate treatment.

A 2011 study of indigent patient care in the Philadelphia area conducted by Dr. Shreya Kangovi, PCP, at the University of Pennsylvania hospital, found that indigent patients were willing to wait for their condition to worsen, to the point of needing ambulance service to the ED, so they were assured access to care. A study in neighboring New Jersey by Dr. Jeffrey Brenner, director of the Camden Coalition of Healthcare Providers in New Jersey, identified additional perceived benefits of ED care. Patients indicated their preference for the ED due to the “one-stop-shopping” nature of the hospital. Ambulatory care requires travelling to multiple locations, and many indigent patients have limited or no access to reliable transportation.

Again, might telephone triage be used to avert these ED presentations altogether? But even if it could, Andis Robeznieks, reporter at Modern Healthcare, in an article posted July 8, 2013, pointed out that based on interviews with forty of the hospitalized low-income patients from Dr. Kangovi’s study, low-income patients have more trust in healthcare delivered in the hospital.”

So, what’s the answer? Can the call center work across the healthcare delivery system to team not only with area hospitals and PCPs but also emergent and urgent care centers, wellness and preventive care facilities, and other services often attained by Medicaid patients in the ED? If so, by creating a network of healthcare providers willing to accept and treat patients with lower paying insurance plans within reasonable timeframes, call centers can build trust in patients so they are confident in the information and resources provided and will act on it. Otherwise, it is estimated that the ACA, by increasing insurance coverage to individuals who in the past had none, will exacerbate the problem of ED overcrowding by an additional 134 million publically insured patients.

Mark Dwyer has 27 years of experience in the healthcare call center industry. He joined LVM in 2003 and serves as the company’s COO. Prior to that, he held senior positions in the areas of training, product management, and product marketing.

[From the August/September 2013 issue of AnswerStat magazine]