At the current growth rate, high deductible insurance plans offered through employers will predominate within four years. This has broad implications, which are only beginning to be felt.
The first impact will be a significant reduction in employee health plan loss ratios. Initially, corporate health plan margins will improve significantly. However, federal caps on how the profits can be used will create a crisis for many commercial plans, which are not wired to make investments in member health.
Most provider services, such as emergency rooms, depend on commercial traffic to cover the negative contribution margins of Medicare and Medicaid beneficiaries and especially “self pay” users of emergency services. Cost shifting is rampant throughout the system and for good reason: it has been the only way to pay the rent.
As a provider of nurse advice line services, we are seeing requests from patients to provide recommendations for care that do not involve an ambulance ride or the Emergency Room. This is new and a direct result of high deductible plans. Our nurses make recommendations based on clinical guidelines and judgment, not based on patient requests. This trend is a patient safety issue.
There may not be a broad and sweeping solution to this problem—it can be mitigated with some basic blocking and tackling though. For example, we know from our own experience, national studies, and the experience of other providers that nurse line services recommend about 20% of their callers to the ER. We also know, from the same sources, that if we escalate an ER recommendation to a primary care physician immediately, we can reduce that 20% by 50%—leaving a 10% ER referral rate.
How does this work and what are the barriers? When a nurse reaches an ER recommendation with a patient, the triage software automatically pages the patient’s primary care doctor, which is in the system, to call the patient. Sounds simple? It can be if the patient has a primary care physician, and we have access to the “on call” schedule. In fact, it works quite well today.
If the patient does not have a primary care physician, there is obviously no one to page. This is changing: many health plans require patients to have primary care physicians. Numerous studies have shown this to be one of the best ways to improve patient health, safety, and quality of life.
All too often there is no reimbursement model for the primary care physician to take the page—it is just added to the workload. It is in the interest of health plans to change this. Some provider networks actively work with their health plan partners through an incentive program that produces a significant reduction in ER utilization based on medical necessity.
We recommend bringing Emergency Rooms into the partnership. As pressure mounts from the high deductible plans, ERs would provide secondary triage as an in-network service to their health plan partners. The overhead for seeing a patient who does not need to be in an ER versus the overhead of taking a page will be significantly less for both hospital and plan. It looks like a win-win for both plan and partner.
And the ER and their associated network have an opportunity to provide a critical service that will improve patient safety and satisfaction.