The Opinion Pages | CONTRIBUTING OP-ED WRITER

How to Solve the E.R. Problem

MAY 6, 2015

BACK in 2009, a big selling point of health care reform was the idea that expanding insurance coverage would increase Americans’ access to preventive and primary care and decrease the unnecessary use of emergency rooms, saving billions. President Obama said it this way: “One of the areas where we can potentially see some saving is a lot of those patients are being seen in the emergency room anyway, and if we are increasing prevention, if we are increasing wellness programs, we’re reducing the amount of emergency room care.”

There is one big problem with this logic: data. A new survey by the American College of Emergency Physicians found that 75 percent of emergency room doctors reported increases in patient volume since the Affordable Care Act went into effect. There was a similar result when Oregon introduced a limited expansion of Medicaid in 2008. Researchers at Harvard and M.I.T. found that, 18 months after the expansion, per-person emergency room visits among the new Medicaid patients had increased by 40 percent. This was most likely because previously uninsured individuals could now go to emergency rooms without owing a co-pay.

Opponents of the Affordable Care Act point to these increases as confirmation that yet another promise of the law was false. But these failures do not mean that the emergency room problem is unsolvable, just that insurance coverage alone is insufficient.

In Seattle, an unusual partnership seems to have found a solution. Group Health Cooperative of Puget Sound, a nonprofit that provides health care and insurance, and SEIU Healthcare NW Health Benefits Trust, which delivers health benefits to thousands of home health care workers, have reduced emergency room use among a subset of the trust’s membership by 27 percent over four years.

This was accomplished in a group of roughly 13,500 members whom many health policy experts consider the hardest to change: a population that is predominantly female and minority, between the ages of 46 and 64, whose primary language isn’t English, who are geographically dispersed with no central work site, and who suffer from multiple chronic conditions. They were found to be the sickest and most expensive set of non-Medicarepatients in all of Group Health.

The partnership realized that providing insurance was not enough. Instead it adopted a four-pronged strategy.

First, it offers a $100 cash incentive if workers complete four steps. The steps evolve each year but have included signing up for MyGroupHealth, an online platform where workers can email doctors, order prescriptions, and access health information and self-help resources; completing a “health risk assessment,” a tool commonly used in corporate wellness programs; and completing preventive primary care and dental appointments.

Second, it increased the co-pay for an emergency room visit to $200, while the out-of-pocket charge for an urgent care visit remained at just $15.

Third, it introduced a “Care Begins With You” social media campaign to educate workers about the proper use of the emergency room. The campaign includes a short video that workers view as part of their re-certification process. It reinforces the co-pay information and explains the differences between urgent care and emergency room care. Urgent care is the place to go for coughs, headaches and back pain, while the emergency room should be reserved for life-threatening conditions, like crushing chest pain.

Finally, the partnership took steps to remind workers of the locations and hours of urgent care centers, how to schedule appointments there and with primary care doctors, as well as about Group Health’s 24-hour consulting nurse advice line. Group Health also started a case management program to provide individual support to people who still used the emergency room more than five times in a 12-month period.

Why has Seattle succeeded where Oregon and similar efforts to expand health insurance failed? The answer probably lies in what has become a buzz phrase in health care: patient engagement. Changing behavior is very hard. It can’t be accomplished just by providing insurance or a wellness program and wishing people good luck. Indeed, Mr. Obama overstated how easily expanding insurance would reduce emergency room use.

But the Seattle partnership shows that it is possible to engage — and change the behavior of — even the most difficult-to-reach patients. Probably the most unusual aspect of its program is paying patients to do something that is good for them. A $100 incentive may not seem like much, but for low-income workers making an average of $12 an hour, it is the equivalent of a day’s earnings. By persistently educating patients, the program has helped them effectively navigate the health care system. As a result, these workers avoided nearly 1,200 unnecessary emergency room visits since 2010.

The good news is that this strategy is not neurosurgery. It is a relatively simple set of interventions that could easily spread to almost every other employer and insurer. This is how we’ll finally deliver on the president’s promise — and save all of us billions of dollars.