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Consumers Are Avoiding the ER - But Not in Favor of Telehealth

Researchers at Brigham and Women's Hospital have found that consumers are skipping the ER in favor of urgent care and retail clinics. But they're still not using telehealth for non-urgent care concerns.

Source: ThinkStock

By Eric Wicklund

- Hospitals and health systems are launching direct-to-consumer telehealth platforms to push people with non-acute health concerns away from the emergency department and toward virtual visits. But while new research suggests ED traffic is decreasing, consumers are instead flocking to urgent care and retail clinics.

In a study of ED patterns from 2008 to 2015, researchers at Boston’s Brigham and Women’s Hospital found that ED visits decreased by 36 percent over that time, while visits to non-ED venues surged by 140 percent. But that increase consisted primary of traffic to urgent care centers (119 percent) and retail clinics (214 percent).

For telehealth, meanwhile, the number of ER visits replaced by a virtual consult jumped from 0 in 2008 to six in 2015.

The study, posted online in JAMA Internal Medicine, indicates consumers are becoming more comfortable with seeking alternatives to the ED for non-urgent care, but they’re still more comfortable with in-person care than a telehealth or telemedicine platform.

“The drop-in emergency department visits are quite striking and represent a substantial shift in where patients go to get care for conditions such as sore throat and minor injuries,” Sabrina Poon, MD, MPH, who was an emergency physician and research fellow at BWH when the research was conducted, said in a press release issued by BWM.

READ MORE: Partners, Teladoc Launch Direct-to-Consumer Telehealth Service

“The observed increase in visits for treatment of low-acuity conditions was primarily associated with an increase in visits to urgent care centers, which are now the acute care site at which low-acuity conditions are most commonly treated,” the study noted. “Possible reasons for this recent increase include an increasing number of clinics, familiarity and acceptance of urgent care centers as credible alternative venues for unscheduled care for acute conditions, the ability of urgent care centers to treat a wider range of conditions than retail clinics or telemedicine, greater convenience with shorter wait times than EDs, and lower out-of-pocket costs for consumers.”

The BWH study touches on a trend among hospitals and health systems to shift unnecessary traffic out of the ED and into alternative care, reducing the strain on overcrowded and understaffed emergency departments and giving consumers more timely and less expansive access to care. That’s the reasoning behind the direct-to-consumer telehealth movement.

But for the past couple of years, some healthcare executives have lamented that they’re virtual care service isn’t catching on as quickly as they’d like.

“Utilization does take time,” Peter Antall, founder and chief medical officer of the Online Care Group at American Well, a partner in platforms launched by, among others, Nemours Children’s Hospital, Intermountain healthcare and the Cleveland Clinic, said at a 2017 American Telemedicine Association conference panel discussion. Healthcare providers launching new telehealth platforms, he said, should expect anywhere between 5 percent and 30 percent of their patient population to move to digital health at the onset.

More recently, in an effort to compel consumers to switch from the ER to another form of care, Anthem launched a policy among Blue Cross and Blue Shield plans in several states to review ER treatments with an eye toward rejecting reimbursement for non-urgent care that could have been accessed elsewhere. That drew a sharp response from the American College of Emergency Physicians (ACEP) and Medical Association of Georgia (MAG), which filed suit against BCBS of Georgia charging the health plan with putting its members in a position of having to define an emergency.

READ MORE: How One Urgent Care Clinic Uses Telehealth to Find its Niche

The BWH study, meanwhile, uncovered more interesting data points.

The researchers, who drew their data from Aetna commercial health plans, also found that visits for non-acute care across all platforms increased by 31 percent over that eight-year time period. In addition, healthcare spending on low-acuity treatment increased by 14 percent, though much of that is attributed to a jump of almost 80 percent in ER costs associated with low-acuity care.

This suggests that alternative venues like retail and urgent care clinics and telehealth, which are less expensive and easier to access, are prompting more people to seek care for minor issues, and thus driving up the overall cost for care.  The researchers called it the woodwork effect – “where people who would not otherwise seek care come out of the woodwork to get care.”

That was the take-away from a well-publicized 2017 study by the RAND Corporation, which found that 12 percent of telehealth use replaced office and emergency room visits while 88 percent represented new use of medical services.

“These findings suggest retail clinics do not trim medical spending, but instead may drive it up modestly because they encourage people to use more medical services,” Dr. Ateev Mehrotra, an associate professor at Harvard Medical School and an adjunct researcher at the RAND Corporation, said of the study. “Retail clinics do offer benefits such as easier access to medical care, but the widely expected cost savings may not be realized.”

READ MORE: Spectrum Health Tackles the Flu With Direct-to-Consumer Telehealth

Several telehealth and telemedicine advocates disputed the RAND study, saying connected health services need to be measured differently.

The BWH researchers did note a few limitations to their study. First, they didn’t include office-based visits, and they focused on individuals with private health insurance who are younger than 65 – taking the Medicare and Medicaid populations out of the equation. They also admitted they might not have been able to identify all urgent care and retail clinics, and weren’t able to distinguish between hospital EDs and free-standing EDs.

All the more reason, one of the study’s authors said, to keep an eye on this trend.

“The increasing popularity of alternatives to the emergency department is likely being driven by a variety of factors, including cost, convenience, and long wait times,” Jay Schuur, MD, MHS, an emergency physician at BWH, said in the press release. “In the next few years, it will be important to see how these trends evolve and whether the growth of alternative sites results in lower cost care or more use of medical care.”

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