Outpatient costs, patient navigators

The Affordable Care Act required health plans, including FEHB plans, to liberalize out of network emergency room care. Medscape reports that "In a survey of US emergency physicians, more than 80% said emergency visits are increasing in their emergency department (ED), with roughly half reporting significant increases, and more than 90% expecting increases in the next year." While the increase cannot be blamed entirely on the Affordable Care Act, the liberalized coverage must be contributing to this trend. Meanwhile Medpage Today observes that

Although hospital outpatient care makes up only 5% of all outpatient visits in the U.S., it accounts for more than one-fifth of outpatient costs, according to Agency for Healthcare Research and Quality researchers.

Looking at 2008 data from the Medical Expenditure Panel Survey, Steven Machlin and Sadeq Chowdhury, PhD, found that the lion's share (91%) of outpatient visits occurred in office-based settings, "but these visits accounted for only 64% of all ambulatory physician visit expenditures" due to the higher cost of hospital outpatient care.
The remaining 36% of outpatient care costs were divided between hospital outpatient care (22%) and emergency department care (14%), according to the study.

The average cost of an office-based visit was $199, compared with $922 for emergency department (ED) visits and $1,275 for hospital outpatient visits, the investigators wrote. "Physician visits in [hospital] outpatient settings were considerably more likely to involve surgery than other settings, which contributed to the notably higher outpatient expenses per visit."

Among visits where no surgical procedure was involved, expenses per visit were generally highest for the emergency department and lowest for office-based visits, they noted.
Interestingly, a higher percentage of hospital outpatient visits -- 58.4% -- had no out-of-pocket costs for patients, compared with office-based visits (44%). For those visits that did involve out-of-pocket expenses, the average expense was much higher for hospital outpatient visits ($121 versus $29).

FEHBlog emphasis added.

Health Leaders reported on the coming of age of so-called "patient navigators" -- case managers based at the provider of care's facility rather than the insurer's.

These case managers tend to be registered nurses who sometimes work from a remote location by phone. Or with increasing frequency Cigna, for example, a health plan with 11 million lives, started requiring embedded care coordinators in 2008 when it signed a contract with the Dartmouth-Hitchcock physicians group in New Hampshire. Today it has eight such contracts. And they’re being added “aggressively,” says Cigna spokesman Mark Slitt, with a total of 30 physician practice contracts including that language covering nearly 500,000 lives currently.

Jennifer Farlow, RN, BSN, is one such coordinator. She began in June 2010 with Atlanta area’s Piedmont Physicians Group, which has since added two health coaches and a clinical case manager to help out. Each month she receives a list of patients with the highest medical costs, including their frequency of emergency department use, and a gaps-in-care report listing people with chronic conditions, such as diabetes, who need monitoring. She checks the files for patients who haven’t been in to see their primary care physician in a while. She gets on the phone and calls each one.

What a great idea!