Reducing Emergency Room Utilization

sharing our latest peer-reviewed discovery: by adjusting what type of risk models we used, and how we deployed them, we were able to reduce ED and hospital visits 49% in a Medicaid population through population health teams (p<0.001), relative to standard care management approaches. Moving beyond "risk scores" to "benefit-based" outreach: Nearly all population health programs target patient outreach based on risk scores for future cost or utilization. instead, we learned from the Nobel-prize-winning work of Guido Imbens and colleagues, who created 'heterogeneous treatment effects' statistical methods that helped us identify who would benefit most from different interventions. a patient in the ICU in a coma may be very high risk for future costs, but a phone call from a care manager may not make much impact on their outcomes at the moment. by contrast, a patient with a history of falls who was just prescribed an excessively high dose of a blood thinner may be in a critical window for intervention from a clinical pharmacist. this week, our peer-reviewed prospective cohort study with colleagues at Providence Health System in Washington was published in the journal Health Services Research, showing the results of our 'most likely to benefit' approach (versus traditional 'high risk' approach): benefit-based targeting reduced ER visits and hospitalizations by 49% (p<0.001 in a matched difference-in-differences study controlling for both measured covariates and unmeasured time-invariant confounders). the two groups did not differ in terms of engagement probability, so success wasn't because of 'cherry picking' easier-to-engage patients, but matching patients to the right interventions at the right time. https://lnkd.in/gUJN9HbK thanks to Parth Sheth and colleagues for leading this work with Scott Anders MD MBA FAAFP CPE Ashley Thurow Andrea Ramirez Lucas Hopkins Keith Payet Stuart Battersby Vidya Iyengar Anand Shah Nina Jain Alice Hm Chen Daniel J. Elliott MD MSCE FACP FAAP Rajiv Patel, MD, MBA, FACP Leelee Thames, MD, MBA Peter Lauterbach Natalie Lopez Shaun Michelle Raleigh Prub (P.K.) Khurana Wael Haidar MD MBA Wesley Wolfe Josh Patten Joel Gray Katerina Guerraz Chad Peel Sundee Easter Stephanie Stitt LISW-S, LICDC Lora Cornwell Judy Zerzan-Thul Christopher Chen, MD, MBA JoeMichael T. Fusco John Kissel Cheryl J. Roberts, J.D. Kate McEvoy Mary Applegate Bruce Vanderhoff

A sizable part of working at an emergency dept is actually not emergency care, but determining where the patients can get the best care: in the hospital, at home, or follow-up with specialist/primary care. Inspiring to see dr. Anna Gislén and colleagues at Region Skåne develop a process that help patients find the right level of care from the beginning, saving patient sitting 8-10 hours at the ED to get a referral to specialist. Instead the ED, primary care and specialist clinics early in the process communicate with each other, make a plan and book a time (often next day) for the patient. This year alone, they estimated saving 2500 patient visits to the ED and 1000 less referrals to the ED. The average waiting time at the ED dropped an hour per patient in average. All by working in new and better ways! Even in 2023, innovation in health care sometime doesn't always require generative AI. 🙂 Ping Linn Kennedy, Stefan Jovinge, Robert Berling, Viktorija Matuleviciene Anängen, Jonathan Ilicki. https://lnkd.in/e8pEiPrk

The highest ROI in healthcare today isn't AI or a new drug. It's an approach that transforms emergency rooms and saves billions. Here's the powerful force revolutionising healthcare: We're talking about community-based care - systems where care doesn't stop at the clinic door. It continues through shared goals, trusted relationships, and peer support. Modern healthcare waits for you to get sick, then treats you expensively. No incentives for prevention. No infrastructure for connection. Meanwhile, hospitals are overwhelmed with conditions they can't solve in exam rooms. 70-80% of health outcomes are shaped by housing, nutrition, transportation, and social support. You can't fix these in the ICU, but if you don't address them, you'll end up there. Community-based care fills this gap: • A community paramedic visiting COPD patients after discharge • A peer coach texting medication reminders • A CHW noticing a broken fridge spoiling insulin These aren't extras - they keep people out of hospitals. The results: • 30-60% reduction in preventable ER visits • $2-3 saved per $1 invested • Lower readmissions, higher med adherence Let's take these examples: Hidalgo County, TX (2011): One of America's poorest regions. 12-month diabetes program with CHWs doing home visits. Results: 84% improved A1C, reduced ER use, cost just $185/year per person. North Carolina (2022): Rural EMS unit launched community paramedicine. Paramedics visited high-risk patients at home. ER visits cut in half. Readmissions down 59%. Patient satisfaction: 92%. New York City (2020): CHWs helped with diet, medication, and care plans in low-income clinics. A1C and BP improved. ER use dropped significantly. Beyond numbers: better mental health, fewer missed prenatal visits, higher healthcare trust, stable home environments. So why isn't this the default? Insurance doesn't pay for checking fridges, giving rides, or preventing crises - even though these moments reduce costs and suffering. This isn't about choosing between hospitals and community. It's recognising that healthy communities reduce pressure on the whole system. Hospitals save lives. But they were never meant to do it alone. If we want healthier people and smarter spending, we need to fund what works: local, human, proactive care. ↓ Thanks for reading! I'm Sam Armstrong, Founder of Kismet Healthcare. If you liked this, follow me for insights on healthcare innovation and building community-driven businesses. Because the science is clear: Community is care.

We’ve all seen ***that*** billboard - flashing ER wait times like it’s a drive-thru - and it’s one of the many reasons health insurance premiums keep climbing 10%, 15%, 20%… year after year 📈 Hospitals and large health systems advertise short ER wait times to pull you in - for a sore throat, a UTI, a minor injury. It feels convenient. It feels fast. But it’s not built for value - it’s built for volume 🏥 Because the reality is this: every ER visit averages around $2,000. That’s not a co-pay - that’s the total cost that ultimately hits you, your employer, and your health plan 💸 Now layer this in: the average deductible for employer-sponsored insurance is about $1,886. On the individual market, Bronze plan deductibless average $7,476 and Silver plan deductibles average $5,304. So for most people, one ER visit = paying out of pocket ⚠️ If you’re a CFO, HR leader, TPA, school district, or municipality designing a benefit plan - this behavior is crushing your numbers. ER utilization for low-acuity issues drives up total spend, and that’s exactly why your renewal comes back 10–20% higher every single year 📊 And here’s where it gets even more important: in Detroit, much of the city is designated as a Health Professional Shortage Area. That means limited access to primary care - and that changes behavior across an entire population 🗺️ If it takes 24 days to see a primary care doctor - but only 8 minutes to get into an ER - you don’t need a PhD in behavioral economics to predict what happens next. People choose access. Even when it costs 10x more ⏱️ But the ER isn’t designed for primary care. It’s designed for heart attacks, strokes, trauma. When it’s flooded with low-acuity visits, everyone suffers - especially the patients who truly need emergent care ❤️ So here’s the big takeaway: if you’re running a health plan - or responsible for one - your performance will continue to struggle until you fix access to primary care. Not tweak it. Not optimize it. Fix it. 🔧 That’s where Direct Primary Care comes in. Roughly 20–30% of American adults don’t have a primary care doctor - and instead rely on urgent care and ERs or go without care completely. That’s not a patient problem. That’s a system design problem 🧩 At Plum Health DPC, we meet those patients where they are - same-day or next-day access, direct communication, no barriers. We also meet employer groups where they are - if you have 1,000 employees who engage with our service, we can build you a custom, near-site clinic. And the results are clear: 40% fewer ER visits, 75% fewer urgent care visits 📉 That’s not just cost savings - it’s better access, better care, and a better experience for patients, employers, and communities. A true win-win-win-win. 🤝 Don’t be fooled by the billboard. Fast isn’t always better. Accessible, relationship-driven primary care is the real solution - and when implemented correctly, it changes everything 🚀

Reducing Avoidable Hospitalisations: A CIO’s View on What Needs to Change The latest AIHW report really hit home for me. In 2023–24, Australia recorded 788,000 potentially preventable hospitalisations, costing the system about $7.7 billion. These are admissions for things like diabetes complications, COPD flare-ups, heart failure, cellulitis, UTIs — conditions that, with the right support and timely intervention, often don’t need to reach the hospital door. And the pattern is clear: • Remote communities are impacted the most. • Lower-income areas see far higher admission rates. • Indigenous Australians have nearly 3× the PPH rate of non-Indigenous Australians. It’s a reminder that hospital care is only one part of the story. The real opportunity lies before people arrive at ED. As a CIO/CDO in the public sector, here’s what I believe we must build next: 1.Predictive & Preventive Analytics Not just dashboards — genuine risk models that identify people likely to deteriorate weeks or months in advance. We should be nudging, supporting, and following up before a crisis, not after. 2.Strengthened Community & Primary Care Linkages Digital tools that connect GPs, community health, allied health, and hospitals — so patients don’t fall through the cracks. Especially in rural and remote areas, tech must close the access gap. 3.A Real Delivery Ecosystem: People + PMO + Partners This is where many programs fail. You can’t reduce hospitalisations with software alone. You need: ✔ clinicians ✔ data scientists ✔ care coordinators ✔ Indigenous health teams ✔ community workers ✔ a disciplined PMO ✔ and trusted implementation partners 4.Governance, Equity & Trust Data must be used safely, transparently, and in culturally respectful ways. If the tech doesn’t feel human and safe — people won’t use it. 5.Targeted Action Where It Matters Most Start with the communities carrying the heaviest burden. If we narrow the equity gap, we lower the cost curve for everyone. A gentle call to action We spend billions every year on conditions we can prevent. As leaders, we have a responsibility to move the system from reactive to proactive — from hospital-first to community-first. I’m keen to connect with others who care about this shift. If you’re working on predictive models, community outreach, chronic disease programs, or digital health integration — let’s talk. We can do so much more when we work together. #Healthcare #Australia #DigitalHealth #Prevention #HealthEquity #Leadership #AIforGood #PublicSectorTransformation Australian Institute of Health and Welfare (AIHW) Australasian Institute of Digital Health (AIDH) Australian Institute of Health Executives (AIHE) eHealth NSW eHealth Queensland Sidney Chandrasiri

A company discovered their employees were using the ER 127 times in one year. For things like pink eye, UTIs, and minor cuts. Average cost per visit: $2,400. Total waste: $304,800. The solution cost $18,000 and cut ER visits 73% in 6 months. Here's what they built instead. A manufacturing company saw their ER utilization spike in the claims data. Not for emergencies. For stuff that could wait—or shouldn't have been ER visits at all. 7:30pm on a Tuesday: Employee's kid has pink eye. Pediatrician's office closed. Urgent care 25 minutes away, closes at 8pm. ER is 6 minutes away and always open. ER visit: $2,400 for a $9 prescription. Saturday afternoon: Employee slices hand cutting vegetables. Needs 4 stitches. Primary care closed. Urgent care has a 3-hour wait. ER gets them in and out in 90 minutes. Cost: $3,100 for stitches that would've been $280 at urgent care. This wasn't employees being reckless. It was a healthcare access problem disguised as an overutilization problem. The company tried the obvious fixes first. Increased ER copays from $150 to $350. Sent educational emails about "appropriate ER use." Put up posters showing the cost difference between ER and urgent care. ER visits dropped 8% and some started not going at all. So they tried something different: they made it easier to NOT use the ER. Implemented a 24/7 virtual urgent care benefit. $0 copay. Available by phone or video within 15 minutes, any time, any day. Physicians can diagnose, prescribe, and order testing. Can even arrange imaging or specialist referrals if needed. Added on-site nurse practitioner 3 days a week. Free sick visits, minor injury treatment, chronic disease management. No appointment needed—just walk up during your shift. Partnered with 3 local urgent care centers. Guaranteed no-wait appointments within 2 hours if you call ahead. Negotiated direct billing so employees don't pay upfront. Total program cost: $18,000 annually ($6K for virtual care, $8K for on-site NP, $4K for urgent care partnership). Year 1 results: ER visits dropped from 127 to 34. Almost all 34 were legitimate emergencies—chest pain, severe injuries, actual medical crises. The 93 visits they eliminated? Moved to virtual care (61 visits), on-site NP (24 visits), and urgent care (8 visits). Average cost per visit: $140 vs. $2,400. Savings: $270,000 in Year 1. ROI: 15:1. But the real win wasn't the money. It was the maintenance supervisor who caught his daughter's strep throat via telemedicine at 9pm instead of waiting until morning when she'd missed school. The warehouse worker who got stitches from the on-site NP during her lunch break instead of burning 4 hours at the ER. Healthcare isn't broken because people make bad choices. It's broken because the easy choice is usually the expensive one. Your job isn't to punish employees for using the ER. It's to build a system where the right choice is also the convenient one.

Most healthcare startups follow the same playbook: 1. Raise millions in venture capital 2. Burn cash acquiring customers 3. Hope to reach profitability someday We took a different approach. Five years ago, we launched Frontier Psychiatry to serve the most vulnerable populations with zero outside investment. Three years later we were treating 4,000+ patients monthly in states with some of America's worst mental health outcomes. And the results are now shown in our peer-reviewed JAMA Network Open study: https://lnkd.in/gcPVuQd8 • 38% LOWER hospitalization rates for our Medicaid patients • 17.9% FEWER emergency department admissions • Similar overall costs to Medicaid compared to matched controls Here's how we made it work: 1/ Serving the underserved is actually good business ↳ While most practices screen out Medicaid patients, we embraced them ↳ Scaled through word-of-mouth from grateful patients ↳ Created positive provider recruitment cycles by offering meaningful work 2/ 100% virtual care removes geography as a barrier ↳ Reached patients across a massive rural state ↳ Eliminated expensive physical overhead ↳ Allowed clinicians to practice from anywhere ↳ Got patients seen within 72 hours of initial request 3/ Revenue before investment, not the other way around ↳ Bootstrap mentality forced resource efficiency ↳ No VC pressure to grow unsustainably ↳ Maintained focus on quality care, not vanity metrics ↳ Reinvested profits into sustainable growth 4/ Take all comers, don't cherry-pick cases ↳ From schizophrenia to substance use disorders ↳ No screening for "easy" cases ↳ Building relationships with referring providers ↳ Creating a true safety net function Most healthcare entrepreneurs assume you must choose between serving vulnerable populations and building a sustainable business. Our data proves otherwise. Not the easy road, but for us, the right one. By actually preventing expensive hospitalizations through timely care, we've created value for patients, payers, and our team simultaneously. The greatest opportunities in healthcare often lie where others aren't looking—with the patients everyone else is avoiding. —----------------------------- ⁉️ What assumptions about healthcare business models need rethinking? Have you or a loved one had trouble accessing behavioral health care? Comment below and let me know. ♻️ Repost to challenge conventional wisdom about startup funding. 👉 Follow me (Reza Hosseini Ghomi, MD, MSE) for more like this.

A 44-year-old man in Canada died after waiting over 8 hours in an emergency room with chest pain. This isn’t an exception. It’s a pattern. What the data shows ✅1 in 10 patients in Canada spend 8+ hours in emergency departments ✅Only ~65% are seen within recommended ER time benchmarks ✅23,746 Canadians died in one year while waiting for medical care ✅Ambulance offload delays often range from 2 to 5 hours, blocking ER flow Emergency departments are where system stress becomes fatal. Clinically: • Chest pain = time-critical • BP >200 = medical emergency • Delays sharply increase cardiac arrest and stroke risk At that stage, outcomes depend less on expertise and more on speed of access. How this can be tackled (practically) ✅Strict time-based escalation for red-flag symptoms like chest pain and stroke signs ✅Dedicated rapid-cardiac pathways inside ERs ✅Ambulance offload teams to free ER beds faster ✅Real-time capacity dashboards across hospitals to divert load early ✅Expand urgent-care centers to decompress ERs ✅Protect staff-to-patient ratios during peak hours ✅Measure outcomes, not averages; averages hide critical delays Universal healthcare only works when access is timely. Emergency care is the real stress test of any system. And right now, delays are costing lives quietly, in waiting rooms.

4 in 10 postpartum women end up in emergency or urgent care in the year after delivery. 3/4 of these visits are for non-emergencies better managed in primary care. Why? Because while new moms' need for health care doesn't just end after delivery, health system attention and support fades away. This #postpartum health care cliff prevents them from connecting to primary care for mental and physical health needs. Our intervention simplified the transition to postpartum primary care, leading to substantial declines in emergency and urgent care visits over the postpartum year. The declines were big--ten percentage point (25%) decline in emergency/urgent visits--and almost entirely for conditions that were non-emergent or primary care treatable. Bridging #postpartumcliffs not only is guideline-based, ethical care, it can also improve health care quality and cost. Full details of our #RCT, just published in JAMA Network Open and led by Anjelica Gangaram, linked in the comments. Thank you to Harvard T.H. Chan School of Public Health for this excellent write-up. Mark Clapp, MD MPH Ishani Ganguli Alaka Ray