Enhance accuracy
2x visits with PCPs
$1.5K saved per visit
Improve health outcomes
The challenge
Identifying and redirecting avoidable ER visits
The high cost of maintenance and limited availability of Emergency Rooms (ER) facilities have become significant concerns for payers, governments, providers, and employers. In 2014, Americans made 136 million ER visits, according to the Centers for Disease Control and Prevention (CDC), and this number is expected to rise. However, the American Journal of Managed Care reports that over 30% of ER visits could have been avoided.
Avoidable ER visits result from a lack of coordinated medical attention, leading to higher care costs, longer wait times, and suboptimal health outcomes. Redirecting just 20% of ER visits to more affordable alternatives, such as urgent care or Primary Care Physicians (PCP), could save $4.4 billion, according to HealthAffairs.org.
A multi-billion-dollar healthcare payer aimed to identify members likely to make avoidable ER visits and guide them toward more cost-effective options.
Key challenges
High ER visit costs and limited facility availability
30% of ER visits deemed avoidable
Lack of coordinated care leading to higher costs and poor outcomes
Need for efficient redirection to lower-cost alternatives
The solution
Redefining ER care management
Identifying factors
Identify avoidable ER visits
Generate 50+ hypotheses
Analyze ER visits causes
Targeted actions
Target 30% high-risk members
Implement alternative care
Prioritize provider actions
Implementation approach
1
Data sources
Use structured and unstructured data
Collect PCP and urgent care data
Analyze provider and member info
2
Data processing and analysis
Apply feature selection
Test data hypotheses
Use analytics for prediction
3
Model development
Create ER models
Focus on low-intensity cases
Target group for care interventions
The impact
Predicting and preventing avoidable ER visits
Key insights
Past ER visits raise risks
Multiple PCP visits double risk
Optimized ER use improves outcomes
Cost savings
$1,500 saved per visit
$10M potential annual savings
Target high-risk members 30% of ER visits deemed avoidable
Advanced analytics
ML and text-mining enhance accuracy
Improve prediction of rare events
Data insights optimize care
Looking ahead
Expand predictive models
Enhance prediction accuracy for broader healthcare scenarios
Focus on preventive care
Implement proactive measures to reduce avoidable visits
Improve member engagement
Develop personalized interventions for high-risk members
