Save Emergency Room Unit

Healthcare

Case II:


The high cost of maintenance and limited availability of Emergency Rooms (ER) facilities are under intense scrutiny by payers, government, providers, and employers. According to the CDC, Americans made 136 million ER visits in 2014 which is likely to increase further. Yet a study in the American Journal of Managed Care, cites more than 30% of ER visits could have been avoided. Avoidable ER visits stem from a lack of coordinated care that drive higher costs of care, longer wait times and worse outcomes. Redirecting only 20% of ER visits to lower-cost alternatives such as urgent care or Primary Care Physicians (PCP) could save $4.4 billion according to HealthAffairs.org. A multi-billion dollar healthcare payer wanted to identify members likely to make avoidable ER visits, and steer them to more cost effective alternatives.
Leading healthcare payer in the US
Reduce avoidable Emergency Room (ER) visits

Developed a framework to predict who is likely to make an avoidable ER visit using machine learning and text mining techniques, to identify up to $10M in annual cost reduction

Members may be visiting an ER unnecessarily for convenience, desire for a more effective PCP, from insufficient co-pay funds, or an unmanaged condition. Using clinical rules, we first identified lowintensity conditions where an ER visit could have been avoided and offered more than 40 hypotheses for factors which could be predictive of avoidable ER visits.

To test these hypotheses, we identified different structured and unstructured data sources such as call center notes,

The solution identified 65% of all avoidable visits among 30% of the population – yielding an opportunity to save more than $10M annually by targeting a small group of Members for alternative care management and provider interventions.

Members with past ER visits are 8 times more likely to visit ER unnecessarily

Members visiting multiple PCP are twice as likely to make an avoidable ER visit

Each avoided ER visit, could reduce cost by $1,500 leading to $10M in potential cost saving

Optimized ER utilization can substantially improve member health outcomes

Ensemble framework of text mining and machine learning methods to improve accuracy in rare event scenarios