TeleHealth Economics: Making a Case for TeleHealth for Non-life Threatening ER Visits Vahé Heboyan, PhD Assistant Professor Director, Health & Behavioral Economics Research lab Clinical and Digital Health Sciences Dept. (706) 721-6962 VHeboyan@augusta.edu Saket Patel MPH Student Phillip Coule, MD, MBA, FACE Vice-Chairman of Clinical and Business Operations, Emergency Medicine and Hospitalist Services Dept. Gianluca De Leo, MBA, PhD Chair and Associate Professor Clinical and Digital Health Sciences Dept. 1
Background Immediate or emergent visits accounted only for 32% of all ED visits in US in 2011 (National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary). ER care not only imposes high economic costs and hardship on self-paying individuals and insurance companies, but also stretches ER resources and may result in payment delinquency. Some studies suggest that a significant portion of ED patients could be treated in physicians offices with the same quality and outcomes (Bamezai et al., 2015). Lower ED costs & cost savings to the health system overall Conflicting results exists on the costs of emergency care compared to similar care outside of ED. e.g. Kellermann (2005) vs. Bamezai et al. (2005) 2
Background: ED Visits, United States 120 122 Total number of visits, millions 129 129 125 131 134 135 2006 2007 2008 2009 2010 2011 2012 2013 40,229 40,611 Rate of visits per 100,000 persons 42,013 42,059 41,694 41,088 42,820 42,663 2006 2007 2008 2009 2010 2011 2012 2013 Source: AHRQ/Healthcare Cost and Utilization Project http://hcupnet.ahrq.gov/ 3
Central Savannah River Area (CSRA) A trading and marketing region. GA (12 counties) SC (7 counties) Population CSRA: 768,402 (2010) Metro Augusta: 580,270 (2013) 4
ED Visits: Georgia 2,764,044 2,710,113 2,800,290 2,616,416 2,495,724 ER VISITS ER VISITS ER VISITS ER VISITS ER VISITS 2010 2011 2012 2013 2014 Source: GA DPH/OASIS https://oasis.state.ga.us/oasis/oasis/qryer.aspx 5
ER Visits: CSRA & Metro Augusta 138,819 135,501 138,435 137,400 141,568 108,209 107,772 109,979 110,029 111,832 2010 2011 2012 2013 2014 CSRA Metro Augusta (Columbia, Richmond, Burke, Warren, Jefferson) Source: GA DPH/OASIS https://oasis.state.ga.us/oasis/oasis/qryer.aspx 6
Mean and Median ED Wait Time, US From 2003 through 2009, the mean wait time in U.S. emergency departments (EDs) increased 25%, from 46.5 minutes to 58.1 minutes. The mean wait time in EDs increased as annual ED visit volume increased. http://www.cdc.gov/nchs/data/databriefs/db102.htm 7
Emergency Severity Index Triage Algorithm Source: ESI Triage Research Team, 2004. 8
The Challenge Many use the ED as their primary or only source of medical care because they are not welcome elsewhere (Kellermann, 2005). After hours ED is the only viable option for those who cannot afford to miss a day of work. Surprising number of patients are sent to ED by health care professionals for reasons not associated with the severity of the patient s conditions. Increasing use of ED and overcrowding is a legitimate concern. Reflects the failure of ambulatory care system Restricting access to ED will not fix the problem 9
The Opportunity Improving access and affordability has the promise to address the problem. Telehealth for ED may be a viable alternative for addressing the problems of overcrowding and increasing wait times. Patients in non-life-threatening conditions (triage 4-5) Use of telehealth for ED visits can especially be important for small, rural hospitals that have limited resources compared to larger, urban hospitals (Wart et al. 2015). 10
Objective The Problem No full economic analysis exists on the economic feasibility of telemedicine applications for ED visits (Wart et al. 2015). small number of studies report only cost estimates. Objective Describe the economic burden of ED visits for patients with non-lifethreatening conditions. Policy Importance Provide decision makers and healthcare administrators with knowledge and tools to guide future ED strategic planning and future research. 11
Data and Method Data from Augusta University Emergency Department 2013-2015 ED visitation Expenditure (facilities and professional) Triage and medical condition Demographics Geographic N=198,338 Assess the full economic value of ED utilization for triage levels. Medical costs Non-medical costs (wait time, transportation) Payor s perspective 12
Results
Demographics 107,073 Gender 91,265 114,305 Race 73,330 5,492 3,704 1,227 173 111 Female Male Black White Hispanic Multi race Asian Unknown Alaska N.American 57,535 Age 20,070 23,097 29,809 23,420 30,311 14,100 1-17 18-24 25-30 31-40 41-50 51-65 over 65 14
Triage Categories 86,832 75,256 23,882 3,557 8,132 Level 1 Level 2 Level 3 Level 4 Level 5 15
Insurance 81,115 56,587 45,945 14,695 Private Public Self Pay Other 16
Number of visits Mode of Arrival 163,103 Mode of Arrival Private vehicle 31,710 Ambulance 3,529 Other 17
Number of visits Admittance Source 192,021 1,957 1,149 1,035 905 658 603 14 Self referral Transfer from diff hospital Physician self refer Transfer from health care Tran from skilled nurse fac Court/law enforcement Physician clinic referral Other 18
Number of visits Discharge Status 189,323 3,880 5,070 Discharged home Left ED Other 19
Length of Stay (days) 153,446 38,980 4,034 1,156 614 46 1 2 3 4 5-10 days 11+ days Days 20
Time in ED* 45,080 44,805 31,285 33,164 23,447 9,593 10,968 <1 hour 1-2 hours 2-3 hours 3-4 hours 4-6 hours 6-12 hours over 12 hours * time in waiting room and treatment room 21
0 200 400 600 Time in ED* (min) by Triage level 631 345 301 154 125 Triage 1 Triage 2 Triage 3 Triage 4 Triage 5 * time in waiting room and treatment room 22
1 Medical Costs Charges Facilities Professional Payments (received) Facilities Professional 23
Charges ( % ) 52.1 57.9 39.08 21.6 29.4 25.86 28.18 20.1 0.32 0.3 1.1 6.55 9.9 6.0 1.7 less than $250 $250-500 $500-1,000 $1,000-2,000 Over $2,000 Triage 3 Triage 4 Triage 5 24
Payments ( % ) 82.9 71.0 47.5 23.4 21.4 14.2 17.1 6.1 2.6 7.0 5.0 1.1 0.2 0.4 0.2 less than $250 $250-500 $500-1,000 $1,000-2,000 Over $2,000 Triage 3 Triage 4 Triage 5 25
Charges & Payments (mean) 14,592 Charges Payments 5,655 2,572 2,876 958 956 515 692 200 131 Triage 1 Triage 2 Triage 3 Triage 4 Triage 5 26
2 Non-Medical (extra) Costs Wait time Wait time in ER * wage rates Miles driven Calculated distance between patient zipcode and AUMC ER using ArcGIS. Used current mileage rate ($0.535/mile) Other costs not accounted for Childcare Escort person expenses Meals away from home Comfort and psychological stress/frustration 27
50, 100, 200 miles service area 95.1 % 2.4 % 1.5 % 1.0 % 0-50 miles 50-100 miles 100-200 miles over 200 miles ER Visits by Distance 28
Extra Cost* of ER Visit $ 250 $ 200 Triage 3-5 $ 250 $ 200 Triage 3 Transport Wait time Total extra $ 150 $ 150 $ 100 $ 100 $ 50 $ 50 $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr $ 250 $ 200 $ 150 $ 100 $ 50 $ 250 Triage 4 Triage 5 $ 200 $ 150 $ 100 $ 50 $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr * Additional costs may include: child care, escort person, comfort and psychological stress, etc. 29
Overall Cost of Visit triage 3-5 $ 500 Total Cost $ 400 Medical cost $ 300 $ 200 $ 100 Extra cost $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr 30
Overall Cost of Visit triage 3 $ 700 $ 600 Total Cost $ 500 Medical cost $ 400 $ 300 $ 200 $ 100 Extra cost $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr 31
Overall Cost of Visit triage 4 $ 300 Total Cost $ 200 Medical cost $ 100 Extra cost $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr 32
Overall Cost of Visit triage 5 $ 200 Total Cost Medical cost $ 100 Extra cost $ 0 Min wage $10/hr $12.5/hr $15/hr $17.5/hr $20/hr 33
Conclusions & Discussion Visits for non-life-threatening conditions (triage 4-5) represent sizable portion of ED visits. Triage level w/out extra cost w/ extra cost Charges Triage 1-5 $ 2,605 Triage 3 $ 2,875 $ 2911 2975 Triage 4-5 $ 951 $ 974 1,006 Payments Received Triage 1-5 $ 471 Triage 3 $ 515 $ 556 620 Triage 4-5 $ 198 $ 222 254 34
Conclusions & Discussion TeleHealth infrastructure is becoming more affordable and efficient. Healthcare providers are already using TeleHealth for other purposes. Smartphone/tablet technologies are making access to TeleHealth more affordable. Has the potential to considerably improve healthcare access and quality at small, rural facilities. 35
Conclusions & Discussion Reimbursement No consistent pattern for coverage and reimbursement has emerged. Is improving with Medicaid s lead. Social adaptability within and outside healthcare community. Misconceptions: will decrease patient-provider relationship, poor acceptance by patients. 36
Limitations ED time not disaggregated by time in wait room and time in treatment room. Not accounting for other economic costs Childcare Meals away from home Escort time and expenses Psychological stress and discomfort 37
Next Steps New Study (IRB pending) Perceptions and attitudes towards utilizing TeleHealth for ED Capturing more accurate economic costs Income, wait time, distance traveled, etc. Willingness-to-pay for TeleHealth for ED Mock TeleHealth session for ER visitors 38
TeleHealth Economics: Making a Case for TeleHealth for Non-life Threatening ER Visits Vahé Heboyan, PhD Assistant Professor Director, Health & Behavioral Economics Research Lab Clinical and Digital Health Sciences Dept. (706) 721-6962 VHeboyan@augusta.edu 39
References Cited Bamezai A, Melnick G, Nawathe A. The cost of an emergency department visit and its relationship to emergency department volume. Annals of Emergency Medicine. 2005;45:483-490. Kellermann. Calculating the Cost of Emergency Care, Annals of Emergency Medicine, 2005; 45(5). Marcia M. Ward, Mirou Jaanab, Nabil Natafgia. Systematic review of telemedicine applications in emergency rooms. International Journal of Medical Informatics 84; 2015: 601-616. 40