Report: Upstate New Yorkers Unnecessarily Use the ER

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Jamie Kerr, M.D., vice president and chief medical officer for utilization management, Excellus BlueCross BlueShield

ROCHESTER, NY (05/26/2010)(readMedia)-- Upstate New Yorkers made more than 640,000 trips to emergency rooms for sore throats, ear aches and other minor medical problems in 2008, raising concerns that such trips are straining already overcrowded ERs, according to a new Excellus BlueCross BlueShield report.

About two out of five visits to upstate New York hospital emergency rooms in which patients don't stay overnight are potentially unnecessary, according to the report, The Facts About Potentially Unnecessary ER Visits in Upstate New York.

"Unnecessary visits can strain overcrowded ERs, possibly delaying treatment for those who truly need an ER, and contribute to the rising costs of health care," said Jamie Kerr, M.D., vice president and chief medical officer for utilization management, Excellus BCBS. "We hope this report will help upstate communities work together on ways to address this problem."

To determine the number of potentially unnecessary ER visits, the report applied a New York University formula that classifies ER visits to hospital data collected by the New York State Health Department.

According to the report:

• One out of four ER visits in which the person is treated and released in the same day was for a medical issue that didn't need care within 12 hours, such as back problems.
• Another 18 percent of visits were for medical conditions that needed treatment soon - such as ear infections - but could have been treated in a primary care setting.
• There is little regional variation in the percentage of potentially unnecessary ER visits in upstate New York.
• A significant amount of health care dollars could be saved in upstate New York if patients went to their physician's office instead of the ER for minor medical problems. Potential annual savings for commercially-insured patients range from $5.9 million to $8.6 million with a 5 percent change and from $29.3 million to $43.1 million with a 25 percent change.
• People unnecessarily visit the ER at all hours of the day and every day of the week. Forty-five percent of such cases are seen between 9 a.m. and 5 p.m.

"The patient's primary care physician should be at the center of the decision-making process when it comes to patients determining whether they should go to the ER for care," Kerr added. "It is important to talk to your physician about alternatives for care for those times when your physician is unavailable."

The report highlights approaches being taken in other states to help people determine the best places to obtain care for minor medical issues. "There are many directions our community could go in responding to this data," Kerr noted. "The findings aren't unique to upstate New York. However, all health care is delivered locally, so we believe the issue is best addressed by physicians, hospitals, health insurers, and other members of the health care system working collaboratively together."

Initiatives that are underway to impact the problem include 'medical home pilots', as well as updating policies that encourage after hours care in physician offices.

"If you're having a true emergency, go to the ER," Kerr added. "But if you have a sore throat, an ear ache or back pain, you really should talk to your doctor. Your problem will usually be addressed more quickly and by someone who knows you best, and your co-pay for a physician visit will be less."

About the analysis

"Many of the figures in the analysis are conservative," Kerr added. "The number of potentially unnecessary ER visits in upstate New York is likely larger since the report did not include visits the NYU formula deemed 'unclassifiable' such as injuries."

The report also looked at health insurer payments for care rendered to commercially insured patients to see how much would be saved if these patients went to a physician's office instead of the ER for minor medical issues. More health care dollars would likely be saved if the analysis also looked at the uninsured and those with Medicare and Medicaid.

To view the report, go to excellusbcbs.com/factsheets and scroll to the "Hospitals" section.

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Excellus BlueCross BlueShield, a nonprofit independent licensee of the BlueCross BlueShield Association, is part of a family of companies that finances and delivers vital health care services to more than 1.7 million people across upstate New York. Excellus BlueCross BlueShield provides access to high-quality, affordable health coverage, including valuable health-related resources that our members use every day, such as cost-saving prescription drug discounts and wellness tracking tools in our Step Up program. To learn more, visit www.excellusbcbs.com.