A mounting trend in costly ER visits should raise some eyebrows among HR/benefits professionals who are working to reduce their company's medical expenses.

Emergency room visits increased from 34.1 per 100 individuals in 1996 to 40.5 per 100 individuals in 2006, according to a new report from the Centers for Disease Control and Prevention.

In 2006, patients in the United States made 1.1 billion visits to hospitals and physician offices - or about 3.8 visits per person annually. The research found some disparities by race and insured status. Black patients had higher visit rates to hospital emergency rooms and hospital outpatient departments and lower visit rates to office-based surgical and medical specialists, compared to white patients, the CDC reports.

"ER use is a serious problem both from a quality and a safety perspective," says Helen Darling, president of the National Business Group on Health.

Higher costs

In almost all cases, treatment in an ER costs much more than treatment at a physician's office. "The ER is the most expensive setting for people to get care," confirms Paul Fronstin, director of the health research and education program at the Employee Benefit Research Institute.

That's why, for years, employers have been educating their employees about why they shouldn't go to the ER for non-urgent conditions, like a cold or flu. But even so, workers often don't understand when they should and should not use an ER, and they don't always realize how long they'll have to wait at an ER, Darling observes.

Sometimes patients feel the need to go to the ER for a prescription or treatment at night or during a weekend, when their primary care doctor's office is closed. "That's often the case," Fronstin notes. Consequently, some experts have called for expanding physician office hours to cut down on the non-urgent ER visits.

Part of the problem is the shortage of primary care doctors in many parts of the country, which means patients might have to wait for too long to get an appointment with their doctor. "We have a primary care crisis in this country," Darling says. "We need more primary care physicians and advance practice nurses in this country."

One downside to the rise in ER visits is the potential for overtreatment, including unnecessary or duplicate tests and scans. "It triggers all these tests. You wouldn't necessarily be treated the same way if you went for an office visit," Fronstin states.

As expected, certain types of conditions are more likely to be treated in an emergency room than in a physician's office or outpatient setting, mainly because of their urgent nature. For example, 42.5% of drug addiction and drug abuse cases are treated in the ER, and 42% of gastrointestinal hemorrhage cases are treated in the ER. More than half of open wounds and head injuries are treated in the ER, according to the CDC.

The uninsured

Research confirms the belief that uninsured Americans go to hospital emergency rooms when they need care, since hospitals cannot legally refuse to treat a patient with an emergency medical condition. Among the uninsured, the visit rate to emergency rooms is about twice the rate of those with private insurance, the CDC reports.

Likewise, cities with higher poverty rates show greater use of ERs and less use of physician office visits, perhaps because of higher numbers of uninsured residents, the CDC notes.

Dr. Prathibha Varkey, a Mayo Clinic physician who works in preventive and occupational medicine, says, "The ER has functioned as a safety net for people who do not have access to health care. Some of this increase in ER visits is a symptom of access issues."

In general, when hospital bills go unpaid by the uninsured, it results in higher health insurance premiums for those with coverage. "That cost is going to get shifted to somebody. Part of it undoubtedly will be shifted to employers," Fronstin explains.

Solutions

Varkey emphasizes the need to focus on wellness and prevention - through worksite wellness programs, onsite health screenings, health risk assessments and employee assistance programs. She calls for "integrated, well thought-out, population-based approaches for enhancing quality of care," which can include treatment protocols, nurse triage lines, case management and disease management programs.

Fronstin suggests several other solutions to reduce the number of unnecessary ER visits: increase the copay that employees must pay if they visit an ER and are not admitted to the hospital; advocate for 24-hour urgent care clinics; and provide a 24-hour nurse hotline as part of your health benefits. The nurse can quickly give a person advice about whether his or her condition requires a trip to the ER or not.

In fact, 40% of callers to Mayo Clinic's 24-hour nurse hotline choose a lower level of care at the conclusion of the call than they originally intended to seek. About 60% of callers whose initial intent was to go to the ER are redirected to a lower level of care, and 90% of callers agree with nurse's recommendations.

To further encourage employees to use lower-cost settings when appropriate, Darling recommends offering a lower copay for visiting a retail health clinic instead of an ER.

In addition, she suggests, it helps to have good communication with employees about where they can find a retail health clinic or an urgent care center near their home. Medical care tends to costs less in those settings, and it's best to have the location information before an illness or injury occurs.

Tips for preventing unnecessary emergency room visits

1. Offer a 24-hour nurse line that workers can call to figure out whether their condition warrants a trip to the ER.

2. Provide disease management programs that help employees keep their chronic conditions from getting dangerously out of control.

3. Offer wellness programs that motivate workers to exercise, eat healthy foods and not smoke. With a better fitness level, they're less likely to get injured and need the ER.

4. Tell employees where to find retail clinics and urgent care clinics near their home and office.

5. Lower the copay for visits to retail clinics and raise the copay for those who visit the ER without being admitted the hospital afterward.

6. Provide self-care guidebooks that tell employees when an ER visit is needed and when it's not needed.