Delivery of acute unscheduled healthcare: Who should judge whether a visit is appropriate (or not)?

May 9, 2018

Delivery of acute unscheduled healthcare: Who should judge whether a visit is appropriate (or not)?

American Journal of Managed Care

Emergency department (ED) utilization has become a hot-button health policy issue. Since the inception of the modern ED, people have debated “appropriate” reasons to seek ED care. More recently, they have wrestled to identify interventions to deter “unnecessary” visits. Determining what might be considered appropriate emergency care is a challenging task and depends a great deal on the stakeholders.

To illustrate the various perspectives regarding appropriate use of the ED, consider these questions regarding a clinical example:

  1. Is acute care necessary? In this case, does the scalp laceration need to be assessed by a clinician?
  2. If acute care is warranted, in what setting should it be delivered (eg, primary care provider office, urgent care, or ED)? Is there a consistent “appropriate” answer or does it depend on variables such as the time of day or day of the week?

The “prudent layperson” standard defined in the Affordable Care Act helps answer the first question (ie, is acute care indicated?) by defining an emergency medical condition. The standard asserts that “if a person of average health and medical knowledge could reasonably expect that their health was in serious jeopardy or their symptoms could lead to serious impairment or dysfunction, then ED care is appropriate.” This broad definition is among the best available to determine ED appropriateness and is arguably better than a retrospective determination, given a level of diagnostic uncertainty prior to clinical assessment. Although this federal standard helps define an emergency, it unfortunately does not assist in directing patients to the appropriate venue of care (ie, the second question), nor do most health systems sufficiently guide patients to the best venue of care.

Enhancing access to primary care may decrease acute ED and urgent care visits. However, do most consumers prefer that their primary care physician treats a sore throat or a sprained ankle? Will the care be better or less costly? A recent study of an onsite medical clinic reported that lowering barriers to primary care visits decreased urgent care visits but did not lower costs. Key variables, such as quality of care provided and patient satisfaction, are often not reported in studies comparing the relative costs of different care venues.

The prudent layperson standard and a federal policy that mandates that all patients receive emergency evaluation and treatment regardless of ability to pay are likely drivers of the consistent increase in the rate of ED visits. Although ED visits contribute to nearly half of the medical care delivered in the United States, “inappropriate” encounters may only represent 3% of the tens of millions of ED visits each year, depending on the definition used.6 Given the real, and perceived, financial burden of unneeded ED visits, multiple interventions aimed at reducing clinically inappropriate ED visits are being explored.

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