A potentially preventable emergency room visit is when a patient goes to an emergency room for a health condition that could have been treated in a non-emergency setting or prevented by keeping them healthier earlier on. Treatment in an emergency room is generally more expensive than a primary care visit. When people have fewer barriers to good health in their communities, and when they can easily access high quality primary care and follow-up, they are less likely to end up in the emergency room. (Patients experiencing a medical emergency should always seek emergency care.)
In Rhode Island in 2014, 46% of Emergency Room visits were potentially preventable for the privately insured population, compared to 70% for people with Medicaid, and 71% for people with Medicare in 2013 (Medicare data is not available for 2014). Compared to rates reported by New York (74%) and Minnesota (65%), Rhode Island had considerably fewer potentially preventable visits among people with private insurance. For the publicly insured population, Rhode Island's performance more closely resembled those reported by Minnesota, New York and Texas.
Potentially preventable emergency room visits accounted for $39.3 million in cost for the privately insured population (2014), $18.0 million for the Medicaid population (2014), and $33.1 million for the Medicare population (2013). While not all of these costs will ultimately prove avoidable, this still represents $90 million in potential savings for Rhode Island's healthcare system, in addition to the potential benefits to patients from better managing their conditions and avoiding the inconvenience, and possible risks of seeking emergency care.
Medicare, Medicaid, and private insurers pay widely different amounts for emergency room visits. Private insurance pays more than three times what Medicaid pays, and nearly twice what, Medicare pays. For each payer type the average costs of potentially preventable emergency room visits were roughly the same as the average cost of Emergency Room visits more generally.
The top reasons for potentially preventable emergency room visits vary by payer type, presenting opportunities for targeted interventions to improve community health. Alcohol abuse, teeth disorders and upper respiratory infections were especially prevalent among the Medicaid population, while chest pain, dizziness and urinary tract infections were particular to the Medicare population. Neck sprains, headache and chest pain were among the top reasons for the privately insured population.
Importantly, the condition that accounts for the most spending – chest pain, which at $5.1 million is nearly twice that of the next highest cost condition – is only the 15th most common potentially preventable reason for emergency room visits in Rhode Island. Although some visits for chest pain may later be identified as potentially preventable, patients experiencing chest pain should always seek immediate medical attention to determine whether or not they are having a heart attack. Emergency room visits for chest pain may be identified as potentially preventable when the patient is not actually experiencing a heart attack, a truly emergent and serious condition, and is not admitted to the hospital(3M® Potentially Preventable Events methodology removes emergency room visits where the patient was admitted). Rather, these patients may be experiencing pain caused by muscles surrounding the chest wall, stomach upset, and/or anxiety. more These findings do not suggest that these individuals should not seek emergency care. Rather, they suggest that keeping people healthy and expanding access to proper and consistent primary care can help reduce the incidence of chest pain in the first place.
While Rhode Island emergency rooms provide vital services to our community, the data indicate that many emergency room visits are potentially preventable. The lower rate of potentially preventable emergency room visits for patients with private insurance may reflect gains from ongoing efforts to improve coordination of care, such as through Rhode Island's patient-centered medical home program. Rhode Island has an opportunity to improve patient care and health outcomes, and lower costs, by reducing potentially preventable visits. This is a target for several initiatives being implemented as part of Rhode Island's Reinventing Medicaid Act of 2015, including the creation of accountable entities to improve care coordination and the establishment of integrated health homes to improve treatment and care coordination for members with serious and persistent mental illness, who have among the highest rates of preventable hospitalizations and emergency room visits. In addition, Rhode Island's Medicaid office will regularly convene a group that includes the state's Medicaid managed care organizations to monitor trends and develop interventions to reduce preventable visits.
Further study of the leading reasons for emergency room use may also help identify interventions to reduce their impact on the community.
These data were analyzed using 3M® Potentially Preventable Events grouping software. These data represent preliminary findings and the most recent data year available. As with any data source, despite robust validation, initial analyses may be adjusted in the future to account for data anomalies not yet identified. Medicaid data (2014) includes Medicaid Fee-For-Service and Medicaid Managed Care plans. Medicare data (2013) includes Medicare Fee-For-Service and Medicare Advantage plans. Private insurance data (2014) do not include Medicaid Managed Care or Medicare Advantage plans offered by private insurers. Data for members who have Coordination of Benefits, meaning they have more than one insurance plan (e.g. Medicare and Medicaid dual eligibility) are excluded from this analysis.