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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2019

Emergency Department Overuse Program

Harvard Pilgrim is committed to improving the quality and value of care for our members, and the physicians in our network are key partners in the pursuit of that goal. In 2019, Harvard Pilgrim has made it a priority to reduce avoidable emergency department (ED) use among our members. Our approach focuses on addressing issues of access to care, offering support and information to our provider network, and educating Harvard Pilgrim members on the medically appropriate use of EDs (the Emergency Care Payment Policy in Harvard Pilgrim’s commercial Provider Manual offers information on the ED services we do and do not cover).

According to data from the Massachusetts Health Policy Commission (HPC), over half of the respondents to the 2014 Massachusetts Health Insurance Survey who had been to the ED in the past year said they had done so because they could not get a timely appointment with their usual source of care. Some potential solutions that could improve access to timely primary care include expanding provider office hours, connecting patients with retail clinics and urgent care centers, and increasing the availability of nurse hotlines and telehealth (which Harvard Pilgrim offers through our telemedicine vendor, Doctor On Demand), and granting nurse practitioners full practice authority.

In the 2016 Cost Trends Report, the HPC reported that 42% of all ED visits in Massachusetts in 2015 were avoidable. As we detailed in this article from the May 2018 issue of Network Matters, this sort of overuse can be combated through methods like identifying the critical characteristics of over-utilizers in this space, developing action plans with ED staff, and supporting primary care provider practices.

At the Massachusetts Medical Directors’ Meeting last spring, Harvard Pilgrim medical directors, the medical leaders of participating hospitals and provider organizations, and other local industry leaders discussed the importance of decreasing avoidable ED visits and addressed potential strategies. You can find the agenda from that meeting and a copy of the presentation on our MA Medical Director Meetings page. Additionally, the Massachusetts Employer Health Coalition has some helpful materials on appropriate ED use that you can share with your patients or hang up in your office, like this poster on when to go to an urgent care center and when to go to the emergency room.

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