How to Improve Your Health Plan’s ER Diversion Strategy


Health plans need to lower ER costs, no matter what type of populations they serve—from Medicaid and Medicare to private, commercial plan members. Non-urgent ER visits cost the U.S. $4.4 billion annually.

Reasons for non-urgent ER visits run the gamut from lack of knowledge to lack of other-care access. One CDC study found that 80% of adults visited the ER because they couldn’t get the care they needed from a primary care physician, i.e., their doctor’s office wasn’t open, they didn’t have a familiar primary care physician or they simply couldn’t get an appointment soon enough. A growing shortage of primary care doctors will likely only compound the issue.

Fortunately, there are several steps health plans can take to turn the tide. We’ve gathered four strategies that can have an impact. These are best-practice tactics gained and refined from our work with more than 75 of the nation’s premier plans.

Four ways to help reduce unnecessary ER visits in your health plan population

>> Proactive member education and engagement

Research shows that a large segment of health plan members are simply unfamiliar with how their insurance coverage works and unaware of care setting options. That makes pre-emptive education critical for helping members receive the right care at the right time while keeping costs down.

This situation is becoming even more important as the emergence of alternative treatment sites—such as urgent care centers, retail clinics, microhospitals and freestanding emergency departments—further complicates consumer choices. A CityMD study found that less than half of survey respondents correctly selected urgent care (versus ER) as the appropriate choice for a scenario in which a child is presenting with 104-degree fever, shivering and coughing.

Based on Carenet’s 30 years of expertise in healthcare engagement, we know that a comprehensive and consistent engagement initiative can help. The strategy should be multi-channel, multi-touch and multi-season. Incorporating information into member onboarding communications and welcome calls works especially well as an educational primer, but a “one-and-done” approach without continuing follow-up won’t be enough to have a lasting effect.

Plans should also consider offering incentives for members to demonstrate their new knowledge, or making ER education more interesting with challenges or online quizzes. The more you focus on proactive member education, the higher the ROI.

Prioritizing targeted population segments, such as high-cost/high-need or ER super users, can drive substantial progress, as well. Personalizing individual communications based on claims, demographic and other data will deliver heightened relevancy.

>> Post-ER follow-up 

Communication and education after an ER visit can also be beneficial in preventing future avoidable use. At Carenet, we’ve seen good results (and in one case, a 3:1 ROI) by conducting follow-up calls within 72 hours of ER discharge.

In one specific client case, our engagement team initiated a quick intervention after one unwarranted ER visit versus the plan’s original strategy of three visits. A list of the most frequent non-urgent ER conditions, such as sinusitis and sprained ankle, was used as the trigger for outreach. The strategy resulted in $14 million in cost-savings over the course of several years.

>> Provider selection and appointment scheduling

Helping healthcare consumers develop a relationship with a primary care physician is important for member health and wellness, as well as appropriate resource utilization and health plan performance.

Selecting a doctor from a plan’s in-network list can be overwhelming, and too many plan websites and provider lists are out of date. That’s why a high-touch communications strategy can make a big difference in helping plan members make their best-fit provider decisions earlier (when there is no pressing care concern) rather than later (when stress and worry levels are high).

Plus, connecting members with primary care doctors helps ensure better preventive care and treatment adherence—which also helps them stay out of the ER.

>> Telehealth care promotion and coordination

Three-quarters of all doctor, urgent care and ER visits are either unnecessary or can be handled safely over the phone or video, and 80% of consumers are open to virtual care for non-urgent conditions.

Many healthcare consumers are simply not aware of the virtual treatment and care options they can access through their plan. That’s why all plans typically need to boost their promotion of their telehealth resources to boost utilization.

Resource promotion should include nurse advice lines, MD e-consults, comprehensive Virtual Clinics and virtual/telemedicine behavioral health access points—and that they are all staffed by the same quality of clinicians found in traditional brick-and-mortar care settings.

Amping up your telehealth communications to members in rural and underserved urban communities is an excellent place to start.

How can we help? As the leader in healthcare engagement and telehealth for health plans, Carenet can help you decrease avoidable ER visits and associated costs with our proprietary Intelligent EngagementTM methodology. To learn more, please reach out today.

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