Preventable healthcare spending in the emergency room topped out at $8.3 billion, according to a white paper from Premier Inc. The paper analyzed 50 ACOs and 750 hospitals across the U.S. to unearth the unnecessary spending.
Premier found that 30 percent of visits to the emergency department could have been treated by primary care doctors or other care settings. The average cost of an visit to the emergency room is estimated to be nearly $1,917 by the Health Care Const Institute, and the study found 4.3 million visits that could have been avoided, resulting in $8.3 billion in wasted payments.
Preventing these visits can be achieved through improving the social determinants of health as well as connecting patients with a primary care provider. But understanding how to manage a disease, improperly using medication, not adhering to doctor’s orders and a lack of access to primary care are all hurdles to avoiding these costly emergency visits.
Hospital systems, health insurers, and nonprofits are all working on ways to avoid these risks, especially with new regulations in place from CMS requiring health providers to show efficiency and a reduction in repeat visitors to the hospital when possible.
CareMore Health, a national network of clinics that work with Medicaid and Medicare patients in Texas, is working to bring team-based care to North Texas. The clinic provides primary care, behavioral health, pharmacy management and more. Patients can have up to four appointments in one visit, depending on their needs. “We are taking care of the patient holistically,” says Karim Kaissi, General Manager for CareMore Health in Texas.
CareMore Health’s goal is to provide care to the complex and normally costly patients before they become so expensive. They focus on maintaining quality while reducing utilization and cost. In an article penned by CareMore leaders in the Harvard Business Review, they describe how collaboration, emphasis on relationships, and social determinants have led to cost savings.
In Tennessee, CareMore reduced hospital visits for aged, blind or disabled patients by 17 percent, reduced ER visits by 21 percent, and knocked specialist visits down 23 percent compared to other groups. In Iowa, CareMore knocked down ER visits for adult women on temporary assistance by 28.9 percent. After opening last year, they look to replicate similar results in Texas.
Many of these patients are not connected to the healthcare system, but CareMore is attempting to remove many of those barriers. They have a mobile team that can meet with patients who can’t find transportation to the clinic, and also employ community health workers to connect the patients with other services that provide housing, food, or other social determinants of health.
“We recognize many agencies and nonprofits that exist within neighborhoods, eliminate waste, and leverage resources within walls of CareMore and outside,” Kaissi says. “Our community team finds resources and organizations that are going to work with us for the betterment of the patients.”
Ideally, the upstream interventions can prevent costly hospital visits, but it isn’t a very popular model just yet, as most hospitals profits come from volume-based revenue. “They need the emergency room volume filling up the beds,” he says.
At CareMore, their funding is per patient, or capitation, giving the clinic incentive to provide the best care at a lower cost. “We get to decide based on our model what kind of resources and care models we can deploy to meet those needs,” Kaissi says.
The patients at CareMore get more time with their physicians, allowing them to address the root causes and reduce costs over the long term. “Our patients require peeling the onion,” Kaissi says.
Finding providers to administer care to a difficult population can be a challenge, but CareMore tries to focus on employees who share their mission, grit, and emotional capacity. Kaissi says they have attracted the attention of providers and lawmakers wherever they have gone.
“We see ourselves as fixing healthcare and putting glue to the broken system,” Kaissi says.