PROVIDENCE, RI — Blue Cross & Blue Shield of Rhode Island (BCBSRI) is addressing unnecessary emergency department (ED) visits through the efforts of an internal task force focused on lowering avoidable healthcare costs. The work of the task force reflects the company’s innovative approach to care coordination and collaboration with providers to reduce unnecessary visits to the ED, keep members healthy and lower healthcare costs.

Since its creation earlier this year, BCBSRI’s ED task force has spurred a reduction in ED visits and significant savings among both Medicare and commercial populations. The multi-disciplinary team identified factors contributing to rising trends of emergency department visits – including use of the ED as a resource for primary care in the absence of having a primary care provider (PCP) – and found opportunities to support members in their decisions about where to seek care. Task force tactics included campaigns launched by PCP partner offices and BCBSRI case management support for members.

“While we certainly recognize that many health situations require emergency department care, we are focused on decreasing avoidable visits to the emergency department, which result in increases in healthcare spend,” said Matt Collins, M.D., MBA, vice president of clinical integration at BCBSRI. “We all have a role to play in lowering healthcare costs, and by educating our members and working closely with the provider community to enhance care coordination, we can realize meaningful savings in healthcare costs.”

Based on BCBSRI claims data 40 percent of ED visits are low-acuity, non-emergent, which means they don’t always require emergency care. For Rhode Island, that 40 percent attributes to $90 million annually in preventable ED visits for symptoms such as back pain, flu symptoms, ear or sinus pain, muscle sprains or bumps, cuts or scrapes. Many of these complaints can be addressed by a PCP, at retail health clinics, or at urgent care centers.

BCBSRI has made tools available to the provider community to help reduce avoidable ED visits. By sharing data on patient visits to PCPs compared to ED visits, providers can address the reasons their patients are seeking emergency care and build programs and services to address patient needs, such as case management for chronic conditions or better support programs for frequently seen conditions. So far, BCBSRI’s task force efforts have resulted in:
• A 3.2 percent reduction in ED use by commercial members, equaling $3.5 million in cost avoidance.
• A .05 percent reduction in ED use for Medicare members, equaling nearly $1 million in cost avoidance. 

BCBSRI’s efforts are also focused on transitions of care, which are spearheaded by nurse case managers who respond to ED visits in real-time and give special attention to members who are managing multiple chronic conditions. By checking in to make sure the member understands their medication instructions and has a follow-up appointment with their PCP scheduled, nurse case managers can keep members out of the emergency room. A key part of their role is to identify members who access the ED frequently, but who do not have an assigned PCP. Nurse case managers work to connect members with an available PCP and provide education on the importance of an ongoing PCP relationship. As a result, BCBSRI has seen a reduction of 15 percent in the number of members who still need a PCP.

“Primary care is paramount in keeping Rhode Islanders healthy, and by visiting a primary care provider, patients can receive care that is comprehensive, coordinated and personalized,” said Charlotte Crist, RN, BCBSRI’s managing director of clinical programs. “Through care coordination, education and close collaboration with the provider community, we’ve been able to decrease avoidable ED visits, which is a critical step in managing healthcare costs and ensuring that those with life-threatening health problems can access the services they need when they need them.”

The task force will now explore more opportunities to support members in finding the right care in the best setting. BCBSRI is providing expanded options for members to engage with their care teams and case managers, including through telemedicine, wellness apps and programs, condition management, and health classes and seminars.

To hear Matt Collins and Charlotte Crist talk about BCBSRI’s emergency department task force, listen to the latest episode of BCBSRI’s Rhode to Health podcast.