A large Health & Welfare Fund with 2,400 members was grappling with the utilization data provided to it by the fund's health insurance vendor. According to the data, the emergency room (ER) utilization was above industry norms and also exceeded the overall experience of the vendor. In addition, 28% of the ER visits were PCP treatable and non-emergent. After studying this data, the Trustees considered raising the emergency room copay from $50 to $75 on the next plan anniversary.
Prior to this time, the Trustees had opted to use informatics software to obtain better analytics. Using this analytical database, we examined the actual utilization patterns of the entire membership and isolated the number of ER visits per member. The unexpected results illustrated that, although the overall ER utilization was high, only 35 high users caused the elevated numbers.
The end result was that the Trustees did not need to increase the ER copay for all 2,400 members but, instead, had their health insurance vendor focus on the high utilizers to see if there was a more cost-effective method to manage the care of these individuals.