We identify a significant fraction of ED visits for non-emergent conditions that could be cared for in UCCs or RCs. Patients may go to an ED for these conditions because of difficulty obtaining accessible, affordable, convenient care for these conditions elsewhere.(1
) We estimate that between 13.7 and 27.1 percent of all ED visits could potentially be seen at RCs or UCCs.
Diverting these patients could potentially decrease their waiting time to be seen by a clinician, since many experience extended periods in ED waiting rooms. There are also potential savings associated with the use of RCs and UCCs. Prior studies have estimated RC and UCC costs at $279-$460 and $228–$414 less than ED costs, respectively, for similar cases.(7
) Assuming the smallest of each of these savings and that 16.8 percent (our mid-point estimate) of the 104 million non-admitted ED visits in 2006 could be seen in one of these alternative settings, the potential savings to the health care system would be approximately $4.4 billion annually, or 0.2 percent of national health care spending.
Our study has a number of limitations. While our ED data are nationally representative, our RC and UCC data come from limited sets of providers. No data were available regarding the proportion of trauma-related diagnoses that could appropriately be treated outside the ED; while we tested a range of assumptions to address this concern, it is only partly mitigated in our estimates. Our analysis also cannot account for the distance between the EDs at which patients sought non-emergent care and any available UCCs or RCs, which could have significant impact on their accessibility. Finally, our savings estimate is predicated three assumptions. The first is that all eligible patients would shift to alternative sites for non-emergent care, finding them accessible, affordable, and willing to provide care to them regardless of insurance status. Second, we assume that RCs and UCCs would be capable of providing care to a greatly increased number of patients. Since neither assumption is likely fully valid, our estimate represents an upper bound on potential savings. Countering this, our estimates also make the third assumption that we capture the full range of services that could be provided at RCs and UCCs in our definition of commonly-seen conditions. This is likely untrue, especially given recent expansions in scope of care at RCs (21
), potentially biasing our estimates downward.
The goal of this work was to estimate the fraction of ED visits that could be seen elsewhere. There are a number of caveats to be considered should policymakers seek to encourage patient use of alternative sites.
First, policy levers to discourage non-emergent ED use may be problematic. While increased copayments can decrease ED use,(22
) their spread has not deterred long-term increases in ED utilization. Another approach is to refer patients to an alternative site after they are triaged. One study found that 52 percent of eligible patients accepted a deferred appointment with a primary care physician,(23
) but this requires the patient to make an additional visit after being seen in the ED, and most EDs will only make a decision to refer elsewhere after evaluation by a physician. Refusing ED services to patients with non-emergent conditions raises ethical concerns,(24
) and some fraction of patients denied care may have urgent needs.(25
Second, there are outstanding concerns about diverting patients away from EDs. Though one study found comparable quality across the three settings,(7
) more research is needed to ensure that equivalent quality is provided at RCs and UCCs. In addition, more rigorous assessments of patients’ ability to appropriately self-triage to the best site are needed. We found that both RCs and UCCs refer less than three percent of patients to other sites, and that the oldest and youngest patients – who are likely to need the most complex services and for whom acute illnesses are most likely to be serious – are more common among ED patients than in the other two settings. These findings indicate that patients are currently self-triaging in a manner that appropriately ensures safety, bringing the most complex and urgent conditions to the ED. However, self-triage might be problematic if larger numbers of patients use alternative sites. In addition, simply expanding the number of alternative sites or promoting their use will not ensure that patients will transfer their care.
Third, there are limitations to realizing any savings estimates. If greater availability of alternative sites induces new demand for care, some or all savings could be offset. Similarly, any increase in reimbursement to RCs or UCCs will decrease savings. Finally, one driver of higher ED costs is that care for life-threatening conditions is expensive. If these costs are spread over a smaller number of total ED visits, per-visit ED costs will rise, decreasing aggregate societal savings.
A continued increase in the number of ED visits for non-emergent causes is likely unsustainable in our current health care system. At the same time, there are calls for health system improvement that focus on increasing quality and patient-centeredness while holding organizations accountable for the cost and outcomes of care they provide. It is unclear what role might exist for alternative sites such as RCs and UCCs in such a framework.
In an ideal world, patients would seek care for non-emergent conditions at their primary care office. While new initiatives such as medical home demonstrations and accountable care organizations (26
) encourage primary care and seek to improve access, this seems unlikely to provide a widespread solution in the near term. Increasingly, acute care is provided outside of the primary care setting. Both the shortage of primary care physicians and the increased number of people likely to seek primary care as insurance coverage is expanded under the Affordable Care Act will likely contribute to worsening primary care access. Recent experience in Massachusetts indicates that such expansions are not likely to lead to a drop in low-acuity ED visits,(28
) indicating a need to further investigate alternatives for providing non-emergent care.