ER visits continue to impact health costs

Limited access creates problems for those seeking behavioral care

DESPITE A GROWING number of free-standing retail clinics and urgent care centers in the state, there is still a heavy reliance on costly hospital emergency department visits, with more than one-third of patients acknowledging their trip to the ER was for a non-emergency condition, including behavioral issues such as seeking treatment for depression, anxiety, and substance abuse.

David Seltz, executive director of the Health Policy Commission, presented data at the annual Health Costs Trends hearings showing the number of free-standing facilities in Massachusetts has spiked since 2010 but costs related to emergency treatment were not appreciably reduced. He noted that those seeking treatment for behavioral issues still find it difficult to access care in non-emergency settings.

“We need to find a way of shifting out of that setting and into the community setting,” Seltz said during a presentation on the first day of the two-day hearing at Suffolk Law School.

The breakdown of non-emergency ER visits didn’t vary much by income as 35 percent of all patients said they went to the hospital for treatment that could have been handled elsewhere. About 40 percent of those below the federal poverty limit went for non-emergency treatment, but those in higher income brackets reported receiving non-emergency treatment at similar rates.

Much of the hospital ER utilization comes as a result of patients, especially those with mental health needs, unable to see a doctor. About 57 percent of those seeking non-emergency treatment said they were unable to get a doctor’s appointment while 68 percent said they were unable to access care after normal working hours.

Manny Lopes, president and CEO of East Boston Neighborhood Health Center, who was part of a panel of five industry officials addressing access to primary and behavioral health care, said his facility has devised an “open access” model that frees up 70 percent of the staff’s workday from appointments to allow for walk-in treatment. He also said the center has an integrated team of primary and behavioral health professionals that allows for a “warm handoff” for those requiring mental health treatment without needing a referral. He said the model has reduced emergency department utilization by the center’s patients by 15 percent.

“We have been able to reduce barriers and create parity for behavioral health,” Lopes told commissioners.

In addition to creating access, expanding the options can reduce costs. According to data from the commission, the average cost of treating a patient at a retail clinic was $69 for all conditions and $149 at an urgent care clinic. The cost of a doctor’s office visit was $165 while a trip to the emergency room was a staggering $894.

One issue in accessing the alternative care sites, said Seltz, is the concentration of those facilities in middle- and upper-income areas. More that 55 percent of the retail clinics in the state are located in communities where the median income is more than $78,000, while nearly half the urgent care centers are in zip codes with similar income.

Of the more than 1.2 million patient visits to the alternative practices, 32 percent were Medicare or MassHealth patients visiting urgent care centers while just 14 percent were those covered by the two public payers visiting retail clinics. Commercial payers accounted for most of the utilization at the free-standing clinics. Overall, 60 percent of patient visits to health care providers in the state are paid my Medicare or MassHealth, with the numbers split roughly evenly between the two. Self-pay barely registers in all payments but comprises a whopping 26 percent of revenue for retail clinics.

Both the commission and the industry officials also said while technology can help reduce costs and increase access and treatment, it’s still a slow slog in implementing and accepting the advances both by providers and patients.

Dr. Wendy Everett, the commission’s vice chair, noted she recently got a flu shot at a retail outlet but said her physician would unlikely be aware of it because the two systems don’t work with each other. Under questioning by some commission members as to why the emergence of electronic health records has done little to unify patient data, several of the industry representatives said there are still bugs to be worked out to get the various systems to talk with each other. But they also noted there is patient resistance to using the platforms to access their own information and even resentment to doctors’ using it during visits.

“Patients don’t like it because I’m looking at a computer rather than looking at them,” said Dr. Gene Green, president and CEO of South Shore Health System.

Green also said the cost of the technology, especially so-called telehealth, is still far more than physical plants. He noted he built a new intensive care unit for $60 million while creating an “e-ICU” would cost twice that and continue to run up in price as updates are released.

One area of technology that doctors say is freeing them up and reducing costs is the emergence of automated transcript programs that can translate notes during visits in a fraction of the time it used to take to write them up.

Meet the Author

Jack Sullivan

Senior Investigative Reporter, CommonWealth

About Jack Sullivan

Jack Sullivan is a veteran of the Boston newspaper scene for nearly three decades. Prior to joining CommonWealth, he was editorial page editor of The Patriot Ledger in Quincy, a part of the GateHouse Media chain. Prior to that he was news editor at another GateHouse paper, The Enterprise of Brockton, and also was city edition editor at the Ledger. Jack was an investigative and enterprise reporter and executive city editor at the Boston Herald and a reporter at The Boston Globe.

He has reported stories such as the federal investigation into the Teamsters, the workings of the Yawkey Trust and sale of the Red Sox, organized crime, the church sex abuse scandal and the September 11 terrorist attacks. He has covered the State House, state and local politics, K-16 education, courts, crime, and general assignment.

Jack received the New England Press Association award for investigative reporting for a series on unused properties owned by the Catholic Archdiocese of Boston, and shared the association's award for business for his reporting on the sale of the Boston Red Sox. As the Ledger editorial page editor, he won second place in 2007 for editorial writing from the Inland Press Association, the nation's oldest national journalism association of nearly 900 newspapers as members.

At CommonWealth, Jack and editor Bruce Mohl won first place for In-Depth Reporting from the Association of Capitol Reporters and Editors for a look at special education funding in Massachusetts. The same organization also awarded first place to a unique collaboration between WFXT-TV (FOX25) and CommonWealth for a series of stories on the Boston Redevelopment Authority and city employees getting affordable housing units, written by Jack and Bruce.

A Boston native, Jack has lived in Massachusetts all his life. He was a major in English and history with a minor in political science at the University of Massachusetts, Boston. A father and grandfather, he lives in Plymouth with his wife, Susan.

About Jack Sullivan

Jack Sullivan is a veteran of the Boston newspaper scene for nearly three decades. Prior to joining CommonWealth, he was editorial page editor of The Patriot Ledger in Quincy, a part of the GateHouse Media chain. Prior to that he was news editor at another GateHouse paper, The Enterprise of Brockton, and also was city edition editor at the Ledger. Jack was an investigative and enterprise reporter and executive city editor at the Boston Herald and a reporter at The Boston Globe.

He has reported stories such as the federal investigation into the Teamsters, the workings of the Yawkey Trust and sale of the Red Sox, organized crime, the church sex abuse scandal and the September 11 terrorist attacks. He has covered the State House, state and local politics, K-16 education, courts, crime, and general assignment.

Jack received the New England Press Association award for investigative reporting for a series on unused properties owned by the Catholic Archdiocese of Boston, and shared the association's award for business for his reporting on the sale of the Boston Red Sox. As the Ledger editorial page editor, he won second place in 2007 for editorial writing from the Inland Press Association, the nation's oldest national journalism association of nearly 900 newspapers as members.

At CommonWealth, Jack and editor Bruce Mohl won first place for In-Depth Reporting from the Association of Capitol Reporters and Editors for a look at special education funding in Massachusetts. The same organization also awarded first place to a unique collaboration between WFXT-TV (FOX25) and CommonWealth for a series of stories on the Boston Redevelopment Authority and city employees getting affordable housing units, written by Jack and Bruce.

A Boston native, Jack has lived in Massachusetts all his life. He was a major in English and history with a minor in political science at the University of Massachusetts, Boston. A father and grandfather, he lives in Plymouth with his wife, Susan.

“I stopped taking notes a year ago,” said Dr. Timothy Ferris, chairman and CEO of the Massachusetts General Physicians Organization. “It has transformed my work life. I used to do four hours of practicing and four hours of transcribing. Now I do four hours of practicing and 15 minutes of transcribing. We are using technology to solve a problem created by technology.”