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The American Journal of Managed Care May 2013
Well-Child Care Visits and Risk of Ambulatory Care-Sensitive Hospitalizations
Jeffrey O. Tom, MD, MS; Rita Mangione-Smith, MD, MPH; David C. Grossman, MD, MPH; Cam Solomon, PhD; and Chien-Wen Tseng, MD, MPH
Differences in the Clinical Recognition of Depression in Diabetes Patients: The Diabetes Study of Northern California (DISTANCE)
Darrell L. Hudson, PhD, MPH; Andrew J. Karter, PhD; Alicia Fernandez, MD; Melissa Parker, MS; Alyce S. Adams, PhD; Dean Schillinger, MD; Howard H. Moffet, MPH; Jufen Zhou, MS; and Nancy E. Adler, PhD
Variability in Resource Use: Diagnosing Colorectal Cancer
F. Douglas Srygley, MD; David H. Abbott, BA, MS; Steven C. Grambow, PhD; Dawn Provenzale, MD, MS; Robert S. Sandler, MD, MPH; and Deborah A. Fisher, MD, MHS
Can Cancer Patients Seeking a Second Opinion Get Better Care?
Hui-Ru Chang, PhD; Ming-Chin Yang, DrPH; and Kuo-Piao Chung, PhD
Medical Costs Associated With Type 2 Diabetes Complications and Comorbidities
Rui Li, PhD; Dori Bilik, MBA; Morton B. Brown, PhD; Ping Zhang, PhD; Susan L. Ettner, PhD; Ronald T. Ackermann, MD; Jesse C. Crosson, PhD; and William H. Herman, MD
Patient Experience Over Time in Patient-Centered Medical Homes
Lisa M. Kern, MD, MPH; Rina V. Dhopeshwarkar, MPH; Alison Edwards, MStat; and Rainu Kaushal, MD, MPH
A Predictive Model of Hospitalization Risk Among Disabled Medicaid Enrollees
John F. McAna, PhD; Albert G. Crawford, PhD; Benjamin W. Novinger, MS; Jaan Sidorov, MD; Franklin M. Din, DMD; Vittorio Maio, PharmD; Daniel Z. Louis, MS; and Neil I. Goldfarb, BA
Pragmatic Clinical Trials: US Payers' Views on Their Value
Jonathan Ratner, PhD; C. Daniel Mullins, PhD; Don P. Buesching, PhD; and Ronald A. Cantrell, PhD
Effects of Integrated Delivery System on Cost and Quality
Wenke Hwang, PhD; Jongwha Chang, PhD; Michelle LaClair, MPH; and Harold Paz, MD, MS
Currently Reading
Emergency Department Use Associated With Primary Care Office Management
Robert M. Goodman, DO, MHSA

Emergency Department Use Associated With Primary Care Office Management

Robert M. Goodman, DO, MHSA
Simple office management techniques should be revisited and given focused attention by primary care physicians to limit emergency department visits for primary care“treatable conditions.
Objectives: The goal of this pilot study is to demonstrate whether revisiting and focusing on simple and generally known primary care officemanagement practices has a meaningful impact on emergency department (ED) utilization for conditions that likely could have been treated in the primary care office setting (primary care physician [PCP] treatable).

Study Design: Cohort study using health plan administrative data from 2007 to 2010 involving primary care physicians (PCPs) affiliated with both Blue Care Network of Michigan, a nonprofit health maintenance organization, and Oakland Southfield Physicians PC, a Metropolitan Detroit independent practice association. PCPs were assigned to cohorts according to pre-intervention increasing or decreasing temporal trends in annual ED visit rates for PCP-treatable conditions by 12-month continuously enrolled commercial members withthe same emergency care copay.

Methods: A difference-in-difference approach measuring control and intervention PCPs for the same 4 months (September-December) during 3 years (2007-2009) pre-intervention, and the available same 4-month period post-intervention, to determine if the pilot was associated with decreased ED utilization for PCP-treatable conditions.

Results: A substantive reversal of a worsening 2007 to 2009 trend (peak of 49.2 visits per 1000 in 2009 decreased to 7.3 visits/1000 in 2010) in ED use for PCP-treatable conditions at intervention sites, with the 2010 rate also lower than control sites (23.8 visits per 1000) during the same postintervention period.

Conclusions: Simple and effective practice management techniques, while generally known, require revisiting and focused attention by PCPs to limit rates of PCP-treatable ED visits.

Am J Manag Care. 2013;19(5):e185-e196
  • There exist simple and largely known primary care office management techniques that may limit emergency department visits for conditions generally treatable in the primary careoffice setting.

  • These techniques are not necessarily well understood or implemented properly by all primary care physicians (PCPs), and should be revisited.

  • Clear direction, support, and follow-up from a larger organization with which a PCP is affiliated (eg, independent practice association [IPA] or accountable care organization [ACO])may be necessary to achieve more consistent and effective use of these techniques within primary care practices.
Emergency department (ED) use as a substitute for primary care physician (PCP) acute minor episodic care has been an ongoing topic of interest in healthcare.1,2 One study that explored non-urgent visits to a pediatric emergency department demonstrated that 62.8% of visits were for parental convenience, and of the 45.4% of parents who did contact their PCP first, 72.6% were referred to the ED.3 Additionally, perceptions of PCP unavailability appear to be a reason why some patients do not attempt to contact their PCP prior to an ED visit. Another study also focused on pediatric emergency care revealed that ED visits for non-urgent conditions were not perceived as a significant enough breach in continuity of care by either PCPs or parents to warrant any concern, and discrepancies exist between PCP and parental perceptions of adequate PCP communication and access.4 Increased ED use is not solely due to the uninsured or those without a PCP, as is often perceived, and thus PCP office  access affects everyone.5 When a problem is identified, our society tends to look for solutions involving innovative complex systems or expensive technology. Awards are not given for revisiting past, less technology-based solutions.The goal of this study is to demonstrate whether revisiting and focusing on simple PCP office management practices, and performing them well, has a meaningful impact on ED utilization for conditions that could have been treated in the PCP office setting.


The Greater Detroit Area Health Council (GDAHC)6 is a multistakeholder organization with the mission of driving collaborative improvements in healthcare quality, cost-effectiveness, and access to care across southeastern Michigan. GDAHC convened a multi-stakeholder team (payers, purchasers, consumers, and providers) to address ED utilization. An outcome of team deliberations was a goal of reducing ED visits for conditions when care likely could have been provided in the PCP office (PCP-treatable conditions) with interventions for improving PCP access.

Blue Care Network of Michigan (BCN) is a nonprofit, statewide health maintenance organization and wholly owned subsidiary of Blue Cross Blue Shield of Michigan (BCBSM). This study used BCN administrative data for commercial members only. The study time frame included the years 2007 to 2010, during which time total BCN commercial membership averaged about 500,000. BCN PCPs are charged with coordinatingoverall care for BCN members and are generally affiliated with a primary care group (PCG). PCGs are not physician practice groups, but rather each PCG is a business entity composed of 1 or more physician practices and functions essentially like an independent practice association (IPA). The PCP practices belonging to a PCG may consist of physicians who are salaried, independent, or a mixture. Generally, each PCP (as opposed to the practice the PCP may belong to) has an individual contract with the PCG with which he or she is affiliated. PCGs vary as to the comprehensiveness and sophistication of their administrative structures in support of the financial goals of the PCG, and in their risk-sharing arrangements both with BCN and with their PCPs. Oakland Southfield Physicians PC (OSP) is an IPA that  operates in Metropolitan Detroit and participates with BCN as a PCG. It consists of approximately 300 primary care physicians. OSP management (both physician and non-clinical) participated on the GDHAC multi-stakeholder team.

BCN and OSP collaborated on a pilot program to study implementation of the GDAHC team’s recommendations for improving PCP access. These recommendations include adopting telephone triage processes and recorded messages that direct patients to the appropriate venue for care; establishing a strategy on how patients can obtain acute minor episodic care when the PCP is unavailable and communicating that strategy to patients; and implementing a scheduling strategy (eg, open-access scheduling) to support same- or next-day appointments including evenings and weekends. Pilot program activities included education of all intervention PCP offices on the initiative and sharing of program materials. Materials were customizable to specific offices (ie, new patient welcome letter and current patient brochure on use of the ED) and also included office procedures for access to care (ie, telephone triage, appointment scheduling, and patient follow-up after a known ED visit). A sample after-hours telephone script was provided, as well as recommendations on how to use the OSP monthly ED visit reports (supplied to OSP by major payers in the area using paid claims data). The launch date of all program tools was tracked and OSP engaged in structured communication with the intervention practice sites at frequent, established intervals to support implementation of the program’s recommendations and tools.

A summary of the OSP intervention site communication program is contained in Table 1. The sample materials, to be edited as appropriate for the actual circumstances of a specific practice, were provided to each intervention site and are contained within the Appendix.


Defining PCP-Treatable Conditions

Different methods for identifying PCP-treatable conditions were evaluated and consensus reached by the GDAHC team, which included representation from primary care,emergency physicians, a major hospital system, and health plans. The final method was also shared with the GDAHC Data Users Group and adopted as part of its future plans forregional surveillance of ED use in the GDAHC service area.

The method chosen was a list of 1231 International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes compiled by BCN and used for various analyses and reports. The diagnosis codes used represent the primary ICD-9 code on an emergency visit claim. Secondary, tertiary, etc, diagnosis codes that may (or may not) be present on a claim were not used to construct the list. The list contained elements of prior lists used by BCBSM and the list of codes contained within the Billings New York University algorithm, updated by using an Agency for Healthcare Research and Quality ICD-9 diagnosis category grouper to aid in the process.7,8 Obstetric ICD-9 codes were excluded, as were any codes not at least 50% of the time also present in BCN PCP office encounter data from a 12-month sample of PCP and emergency claims.

Behavioral health ICD-9 codes were also excluded. Emergency department presentation of behavioral health issues falls into 2 main categories: overt and covert. Overt presentations include diagnoses such as suicide attempt or ideation, psychosis, drug overdose, and alcohol intoxication. Covert presentations include potentially serious physical complaints with a psychological root cause that may or may not reveal itself during the clinical encounter (eg, chest pain in a depressed person to gain attention from family, anxiety presenting as chest pain). While the overt presentations might be considered by some to be PCP preventable (perhaps ED visit avoidable had the PCP better managed a patient’s substance abuse and/or psychological condition), such visits are not PCP office treatable, as the situation has escalated to a more severe manifestation making the emergency department the appropriate venue for evaluation. Patients with covert behavioral health presentations would be less amenable to the PCP access maneuvers described in this pilot, as seeing their PCP may deprive them of the desired psychosocial dynamic that is part of the spectacle of emergency care itself (eg, ambulance transport). Anecdotally, PCPs express that they have little influence in regard to such covert emergency visits and holding them accountable for such visits is unfair. Therefore, behavioral health diagnosis codes were originally excluded to increase provider acceptance of the code list in regard to BCN reporting in general, and remained excluded for the purposes of this pilot program to eliminate the possibility of introducing any bias or detracting from acceptance of this analysis.

The list was edited by BCN staff, which included general emergency medicine, pediatric emergency medicine, internal medicine, and family physicians. The final list consistsof ICD-9 diagnosis codes considered more likely than not for conditions that could be treated in the PCP office setting. The purpose of this type of tool is not for denying claims or making declarations about the appropriateness of a specific ED visit, but rather to follow trends in a population (eg, health plan, PCG- or PCP-affiliated members).

PCP Cohort Assignment and Composition

OSP PCPs were identified who had more than 100 BCN 12-month continuously enrolled commercial members in each of the 3 years from 2007 to 2009 to establish PCP “engagement” with BCN and OSP in general, with this threshold based on prior published BCN research.9 Engagement is important to ensure that a PCP has a sufficient number of patients under a specific contractual arrangement to have interest in any associated  initiatives or programs. Next, to compare “apples to apples,” members with the same benefit design in regard to an emergency  care copay for all 12 months in any given year were identified. A member did not need to have the same benefit design or be a BCN member for all 3 years, but did need to be a BCN member with the same benefit design for all 12 months of any given year. A $50 copay was the most prevalent in 2007 and 2008 for OSP-affiliated BCN members, and the second-most prevalent in 2009. The $50 emergency copay members, of which 99.96% were also with the same PCP for 12 months of any given year, were linked to the OSP PCPs who met the overall engagement criterion. The engaged PCPs were required to have at least 30  such BCN members in each year (2007-2009) to be further considered for entry into either the intervention or control cohort. The count of BCN members who met criteria for study inclusion, by PCP, was used for rate calculations and the 30-member  minimum reduces extreme results due to small denominators while leaving sufficient PCPs to evaluate for inclusion in the pilot.

ED visits for PCP-treatable conditions, as defined by the BCN ICD-9 code list, were tallied for $50 copay members affiliated with BCN/OSP-engaged PCPs who also had at least 30 of the OSP-specific member subset in their BCN patient panel. These counts were then used to calculate ED visit rates, by year, for OSP PCPs that accounted for BCN/OSP engagement and member benefit design. The rates were then trended over 3 years to identify OSP PCPs with ED visit rates that were consistently worsening (yearly increase in utilization), consistently improving (yearly decrease in utilization), or that showed no consistent trend. In conjunction with OSP management, a demographically representative sample of PCPs was selected with a worsening trend for the intervention cohort, and PCPs with an improving or no trend as controls. GDAHC pilot program activities would not be implemented for an identified PCP alone if in a group practice, but rather for the entire office. Therefore, the initially identified intervention and control PCPs were labeled as index physicians and any other PCPs in an index physician’s practice wereidentified and included in the same cohort regardless of the ED utilization associated with the index PCP’s partner(s).

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