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A Bridge To Health — And Away From ER Overuse

By Nancy Wang, North Carolina Health News

March 27th, 2013, 6:01 AM

There are patients in almost every hospital emergency room who do not need urgent care. They are there because they don’t have health insurance or a regular physician, or they didn’t know what else to do. Often, they are repeat visitors. It’s a problem that leads to emergency department overuse and contributes to spiraling health care costs.

Nationally, between 13.7 percent and 27.1 percent of all emergency department visits are non-urgent, according to a 2010 Health Affairs study, leading to about $4.4 billion in health care costs.

North Carolina’s Pardee Memorial Hospital, located in Hendersonville, has joined forces with local physicians in an attempt to reverse this cycle – and program data suggest the plan is working.

In 2009, Pardee’s emergency department treated approximately 45,000 patients. Among them the hospital identified 255 as “frequent flyers” – meaning they used the emergency room six or more times and racked up more than $3 million in unpaid medical bills. They were all uninsured, low-income patients, many with a history of substance abuse or mental health issues.

The next year, 44 of these patients agreed to participate in Bridges to Health – an integrated approach that Dr. Steve Crane, a family physician who started the program, calls a “patient-centered medical home on steroids.” It aims to decrease ER expenses by providing this patient population with primary care, behavioral health services and a nurse case manager through bi-weekly health clinic visits.

The program’s free clinic is part medical check-up, part group therapy. While the doctors treat rashes, abdominal pains and other symptoms, the patients also help one another, suggesting where to seek legal assistance or where to eat or sleep inexpensively. As such, the program sets out to address the two main problems seen in these patients: the lack of social support and access to regular primary care.

Advocates of this type of approach believe targeting ER over-users, who generally have limited experience with the health system, will buttress the Affordable Care Act’s provisions designed to expand insurance coverage and access to care.

A 2011 Centers for Disease Control and Prevention survey reported that 46.3 percent of respondent ER patients were in the ER because they had nowhere else to go. The report also found that uninsured adults were more likely than insured adults to go to the ER for this reason.

“Many of these people just went to the ER because they were in pain or scared,” Crane said. “You see them going back so many times because their real issues are not supposed to be treated in the ER and are not taken care of.”

A Targeted Approach

Unlike most free health clinics, where a wide variety of people are seen individually and most people rarely come more than once, Bridges to Health works exclusively with this specific group of ER over-users and each visit is conducted as one large group appointment.

Crane’s program offers these patients a better alternative with long-reaching benefits.

Before enrolling in the program, participants were averaging seven ER visits a year, costing an average of $14,004 per person. At the end of the first year, participants averaged three visits a year, costing an average of $2,760 per person. This amounted to $404,784 in savings for the Pardee Hospital ER that year.

Additionally, 10 participants found employment and six previously homeless members found stable housing by the end of the first year.

Data for the second year is still being analyzed.

While the results of the program are very promising, Crane cautions that the patient group is small, and that the program only works for participants who come to the clinic meetings.

He and his team, however, are hopeful that programs like Bridges to Health will gain more support because they offer a way to hold down health costs, while improving care. A Bridges to Health pilot is on track to be replicated in Charlotte sometime this year, with a few other North Carolina and Virginia counties hoping to also get on board.

20 Responses to “A Bridge To Health — And Away From ER Overuse”

  1. Lori says:

    This is a great outcome. We need more programs like this. Finding an additional reason for overuse in the population is lack of competency and inability and/or unwillingness for hospitals to address this in the emergency room. Deeper assessment of our frequent fliers re needed on many levels.

  2. Big issue great article. When the estimates are posted:

    “Before enrolling in the program, participants were averaging seven ER visits a year, costing an average of $14,004 per person. At the end of the first year, participants averaged three visits a year, costing an average of $2,760 per person. This amounted to $404,784 in savings for the Pardee Hospital ER that year.”

    Are these dollar amounts what the hospital charges or what Medicare Allows? For instance the hospital may charge $2,000 for a CT of the brain but Medicare will pay $220 which is the Medicare Allowable.

  3. walter says:

    As a Republican, I don’t think this idea has even a remote chance of ever going prime time. Like Obamacare, ideas like this are a complete waste of time. We need to repeal Obamacare and we need to repeal stupid ideas like this. We need to return complete control of our healthcare system to the private insurance companies. America’s healthcare system was doing just fine prior to March of 2010. We need to trust the private insurance companies to do what is best for America’s healthcare system. The private insurers have had decades of experience. The private insurers should be allowed to do as they wish and not be regulated by the federal government. The private insurers can be trusted. We need to let the free enterprise system work. We need to let the free market system work. We need to stop federal government interference. In my opinion, emergency room overuse does not exist. In my opinion, nobody is abusing the emergency rooms in America. How can these statistics be accurate? In my view, it’s impossible!

  4. Lynn in SC says:

    In comparing cost you should also include the cost of the “free clinic”. Some entity is carrying that cost.

    Isn’t interesting that it took so long to identify the frequent flyers and most had mental health or substance abuse issues. These folks have been around for years.

    There are institution by institutions with creative solutions if only someone will look at the patients, recognize the patterns, and lead the solution. As long as providers have their vision limited by what is reimbursed and what is not reimbursed they won’t see solutions that are right under their noses because they only see the lack of revenue tied to these patients. .

  5. Evelyn says:

    Walter, ask anybody who works in any field remotely related to health care and they will tell you that you are dead wrong in your stance on emergency room overuse/abuse. My job involves working with only a small fraction of emergency room patients (only those who receive medical equipment while visiting the ED), and it is alarming how many of these people are “frequent flyers,” coming in monthly, sometimes weekly, for every little thing. (I can only imagine how many more patients I don’t look at that are in the same situation.) But a trend quickly becomes apparent: a strong majority of these patients are unemployed, uninsured or on state assistance, and have mental health and/or substance abuse issues. You cannot just ignore these issues. Private insurers will have nothing to do with these issues. And so we all pay, financially and morally.

    Why on earth would somebody lambast a program actually looking for solutions to these very real problems? I’m so sick of the complainers and naysayers. And it’s a little frightening how much faith you put into for-profit corporations. I sincerely hope that you don’t incur some horrible disease or injury that your insurance won’t cover a lick of, because that is another thing I see constantly in the hospital where I work. Then again, thanks to the Affordable Care Act (or “Obamacare”), you might never have to endure that tragedy.

    You do have one saving grace; at least you acknowledge your rant as opinion and not fact.

    Kudos to innovative thinkers like Bridges to Health.

  6. lisa RN says:

    Walter…do you live under a rock or are you really that healthcare illiterate? The private insurers have turned the healthcare system into profits over people.. Either you are an uber rich republican or you just don’t care about mankind.

  7. walter says:

    Private health insurance companies are what made America’s healthcare system the envy of the world. People are uninsured only because they choose to be uninsured. Private insurers have gone out of their way to make “quality” healthcare affordable and accessible for everyone. Everyone can afford health insurance. Compared to other countries, America’s healthcare is a bargain. That is why the ER overuse claim is completely bogus.

  8. Toni RN says:

    Working on my Masters of Science in nursing and have researched the overuse of the ED extensively. Hospitals across the country are starting programs to assist people with out insurance to obtain primary healthcare services. America has the highest healthcare costs when compared to other countries and we have the poorest outcomes. Rising health care costs account for the our unbalaced budget. Private healthcare insurance companies show 50 to 60% profits and are the main driver of rising healthcare costs in the United States. So called private insurance companies are moving to a managed care model and away from reimbursing for “Cadillac” policies

  9. AJ says:

    Walter’s post is truly spoken like a man who has no idea the burden that modern EDs are forced to bear. This program is great, and it’s only downfall is that more people didn’t enroll. Sure, the clinic costs money. Everything does. But the cost of even a single emergency room visit is staggering. Not to mention that repeatedly visiting the ED does very little, if anything, to actually help this population. Kudos to someone for recognizing a problem and actually doing something about it. I only wish the ED in which I work was so progressive.

  10. walter says:

    Hospitals need to understand that the sky is not always falling and the wolf isn’t behind every tree. I’ve never heard such alarmists in all my life. All of a sudden, after decades upon decades of calm in the healthcare industry, hospital ER’s are now overwhelmed? I don’t buy it. It’s a message of fear. The private insurance companies have been running things pretty well for a very long time. They are the only stakeholder in the industry with the experience and expertise we need to keep a lid on healthcare costs. All we need to do is trust them. Let the private insurers work their free market magic and everything will be just fine. Enough already with the fear. We aren’t believing the lies any longer. Repeal Obamacare, repeal dumb ideas like this and start trusting the private insurers again and healthcare in America will be just fine.

  11. AJ says:

    You are right. Hospitals are not overwhelmed. I am guessing you work in one to have such knowledge and expertise of how underwhelming it is to have a waiting room full of sick people and nowhere to treat them?

  12. Thomas says:

    Walter Dude,

    You have no idea what you are talking about. Anyone who has been involved in healthcare is quite aware of the ER overuse issue. It’s been a concern for decades in the industry. it’s something that we ALL pay for. When people use hospitals for their regular care and cannot pay for it, the hospitals write much of that off as charity care, and they get tax breaks for that. This is an over- simplification the the issue, but it gives you an idea.
    As for your assumption that private insurance will solve all our problems if we just let them work their ” free market magic”, you are totally off base. There can be no true free market with health insurance paying the bills. Fact is, we as consumers have no idea what healthcare truly costs, so we cannot make the informed decisions that consumers make in other markets. A free market doesn’t really work without consumers knowing the value of what they are purchasing, being able to compare providers and choose based upon this information.

  13. Marlon says:

    This is a great article, we really need to prevent over usage of ER, people who must be in this place must be due to urgent or critical medical condition, not those people who don’t have a medical insurance or a regular physician. Anyway, it is still good to know that there’s such program for this matter, free clinic will help not only the patients but the health care team as well for these patients support each other and also they will give advice to one another.

  14. Walter Troll says:

    LOL Walter is being sarcastic..

    Everyone who works in health care knows the facts on the ground and anyone who can read a newspaper knows the US is dead last in terms of cost and quality.

  15. Thomas says:

    ha ha! I wondered…it was so over the top. but then you never know.

  16. Jen says:

    I am a Director of an Emergency Department and I was ready to send Walter to the ED for some serious treatment. :o )

    Until we address health care literacy we will not effectively make headway with this problem. But whose responsibility is this? Parents who are health care illiterate? Schoools who are already struggeling with education standards? Physicians who are seeing the patients who are not over using the ED? Efforts like this are the way. If we can educate the “abusers” of the ED’s then maybe we can not only reduce inappropriate use, but increase the well being of our nation.

    I applaud these efforts and am about to embark on a program such as this. We have 440 patients identified as over users.

  17. Robin says:

    Re: Davis Graham’s comment……..

    “Before enrolling in the program, participants were averaging seven ER visits a year, costing an average of $14,004 per person. At the end of the first year, participants averaged three visits a year, costing an average of $2,760 per person. This amounted to $404,784 in savings for the Pardee Hospital ER that year.”

    Are these dollar amounts what the hospital charges or what Medicare Allows? For instance the hospital may charge $2,000 for a CT of the brain but Medicare will pay $220 which is the Medicare Allowable.

    I love the Bridges to Health program idea and it is obvious it has had success but…..I can’t get over the $2000 charge but accepting $220. Maybe these numbers are not exact but there is definitely a problem with this and it happens with all the fees. I don’t have insurance because I can’t afford it…so how can I pay $2,000 when the insured people only have to pay $220?

    I am desperately trying to figure out where I stand on the health care reform. I have always considered myself to be a Republican but over the last couple of years I have had many, many doubts and I am really leaning toward this health reform and Obamacare. I agree with most all of you, except Walter! That Walter has no clue what is really happing with health care, or lack of it!

  18. walter says:

    America has the best healthcare in the industrialized world. The least cost, the lowest in infant mortality rates, the lowest in uninsured. Why? Because Republican ideas have kept health care control firmly in the hands of the private insurance companies. Obamacare ruins what we have enjoyed for many decades. We need to repeal Obamacare and return to less government intervention. We need to trust the insurance companies like we did in the past. The free enterprise system is the best way to run our healthcare system. Only Republicans can make that happen. Republicans have always watched out for our healthcare system, why change it now? All this talk about ER overuse is just liberal fear tactics. None of it is true.

  19. Tom says:

    Bridge to Health? More like a bridge to nowhere! If anyone can fix healthcare in America, it’s Dr. Rand Paul. He has the answer to ER overuse. The first thing he would do is repeal Obamacare. Then he would get the federal government completely out of all health care services. He would hike Medicare deductables and premiums. Rand Paul is a visionary!

  20. Yikes! One comment ,”trust the insurance companies…” The “decades of experience” the for-profit insurance industry have is finding ways to maximize profits for shareholders.

    Capitalism has worked very well in health insurance — find ways to maximize profits for shareholders.

    In the sneaker business bigger profits mean selling as many sneakers as possible. WIth health insurance, bigger profits mean paying as few claims as possible — that is, find any and every way possible to collect premiums, eliminate coverage for the sick and keep as much money in-house for salaries and shareholder dividends.

    I have no problem with capitalist forces. However, we have seen them work all too well in healthcare to the point where we have 48 million uninsured. Now that is a public health crisis that needs addressing. Obamacare is a start.

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