Patients that have had the misfortune of going to a hospital emergency room (ER) for healthcare know the long wait time and anxiety is best avoided. In addition to being potentially traumatic for patients, ER visits are the costliest site of care by a landslide, with an average ER visit costing employers $1,800 and employees $922 in out-of-pocket expenses. Further, they can signal a cascade of costly medical interventions, with 70% of hospitalizations stemming from visits to the emergency department. Whereas many ER visits are necessary, statistics show many can be avoided.
A meta-analysis of 11 studies identifies predictors of individuals with high rates of ER utilization, classified as four or more ER visits in one year. People who frequently use the ER for healthcare typically display the following social determinants of health:
- The majority are young and middle-aged adults, with a slightly higher percentage being women.
- 60-70% have less than a college degree and earn lower than average income.
- When asked to self-describe their health status, the majority perceive their own health as ‘Poor’ or ‘Fair’.
- 60-70% have previously been diagnosed with a mental health condition.
- 51% currently use tobacco products or have used tobacco products in the past.
- Those diagnosed with the following conditions are 28 times more likely to have high rates of ER utilization: chronic obstructive pulmonary disease (COPD), asthma, diabetes, coronary artery disease, migraines, chronic pain, a prior stroke, allergies, cancer, HIV, hepatitis C, a current or previous pregnancy, have previously given birth, and/or are post-partum (a period that lasts 6 weeks after childbirth).
- Each additional condition adds a 43% increase in likelihood of high ER utilization.
- The presence of three to five simultaneous conditions increases the likelihood of high ER utilization by about five times.
Perhaps most alarming is that the ER is not the only place high utilizers are receiving care. Most have health coverage and on average, they attend 5.5 outpatient office visits per year.
Though sobering, these statistics provide a silver lining in that they point to many issues that can be managed or avoided through a well-designed, empathic health insurance program, such as ClearPoint Health’s captive.
Standard Captives Fuel a Vicious Cycle
Since 2020, more small and midsize employers (SMBs) are leaving fully insured employee benefits plans for captive insurance programs, a type of alternative funding solution. In addition to shared risk, long-term stability, and deeper insight into claims data, one of the benefits of participating in a captive insurance program is cost management. However, not all captives take a fair and sustainable approach to cost management.
In fact, most mainstream captives do employer members and their employee population a disservice by focusing on cost containment at the expense of quality of care. They connect employers with one-size-fits all point solutions that fail to provide the specialized care members of their employee population might need to manage health issues. This includes everything from diabetes management to programs that address lifestyle factors that can lead to or exacerbate existing conditions, such as initiatives that promote quitting smoking or engaging in more physical activity. Lack of specialized care that addresses specific issues increases the likelihood that conditions will escalate, prompting at-risk members of the employee population to seek emergency care.
Finally, most mainstream captives perpetuate this cycle by rewarding all employer members with underwriting surplus, no new laser provisions, favorable rate caps and renewals, regardless of whether they properly address avoidable risk among their employee population or contribute to the sustainability of the captive.
How ClearPoint Health Approaches Avoidable Utilization with Empathy
With widespread issues such as avoidable ER utilization in mind, ClearPoint Health has designed an evolved captive program that considers the people behind the claims. For employers looking to manage avoidable ER utilization among their employee population, ClearPoint’s evolved captive model offers:
- Configurability: In ClearPoint’s captive model, employer members choose their preferred third-party administrator (TPA), pharmacy benefit manager (PBM), network, and point solution configurations. Configurability allows SMBs to customize their employee health benefits plan to fit the unique needs of their employee population.
- Measurement and Support: Upon joining a ClearPoint Health captive, employers are given a custom playbook with specific actions they can take to address avoidable risks and manage costs. ClearPoint understands that difficult conversations are sometimes necessary to drive lasting behavioral change among an employee population. Thus, ClearPoint’s Client Success Team is available to support every step of the way.
- Incentives: Those that take advantage of resources such as their custom playbook and access to the ClearPoint Health Client Success Team rank highly on ClearPoint’s proprietary Member Engagement Index (MEI), which measures employer members’ efforts to manage avoidable and addressable employee healthcare claims costs. High-ranking employer members are rewarded for contributing to the captive’s sustainability with incentives including no new laser provisions, the distribution of underwriting surplus, favorable rate caps and renewals.
ClearPoint’s Captive: Governed Equitably. Built with Empathy. Evolved? Clearly.
ClearPoint Health is all about empathy. ClearPoint understands that not all risk should be insured, so the MEI acknowledges and rewards employer members who mitigate addressable and avoidable expenses. ClearPoint also understands that sustainable insurance is achieved by driving lasting behavioral change in an accountable community. Unmatched customization and comprehensive support help employers help their staff.
By: Chrissy Ogle, Chief Administrative Officer
