In 2014, a record 141 million patients (PDF) visited US emergency departments (EDs). As the nation’s health care system looks for ways to reduce unnecessary treatment and spending, health policy experts have debated how many of those ED visits could be avoided, and exactly what constitutes an “avoidable” visit. Whatever side one may take in this debate, the number of ED visits grew faster than the overall population for the decade ending in 2015, according to a recent article in Health Affairs.

Many industry leaders believe that demand for ED care could be reduced through smarter management of chronic diseases in primary care settings along with easier access to mental health and substance use disorder treatment. Achieving gains in this arena would not only be important for the national health system, it would confer a significant benefit to Medicaid programs and safety-net providers. In 2016, California’s Medi-Cal — the nation’s largest Medicaid program — was projected to pay for 43% of all ED visits in the state.

While “avoidable” ED visits are not a top driver of overall health spending, it’s clear that “a subpopulation of ED patients can be better treated elsewhere at lower costs,” said Renee Hsia, MD, MSc, an emergency medicine professor and researcher at UCSF. “There are plenty of people who don’t have access to timely primary care, and then they come to the emergency department for things that could be done in outpatient clinics or a primary care doctor’s office.”

Among people visiting an ED for a potentially avoidable reason, she said, the top complaints are toothache, back pain, headache, symptoms of psychosis or anxiety, and throat soreness. When those people leave the ED, the three most common diagnoses placed in their records are alcohol use disorder, dental conditions, and depression and other mood disorders, Hsia said.

Technologies That Could Avert ED Visits

The CHCF Innovation Fund focuses on improving health outcomes for vulnerable Californians through better access to care and technologies — including solutions that help patients enhance their health status and avoid preventable ED visits. Some of the Innovation Fund’s investments are geared toward helping patients better manage chronic conditions that, when not controlled, can spiral into costly, life-threatening medical emergencies. Two of them are Propeller Health and Quartet Health.

New York-based Quartet Health is a five-year-old company trying to break down barriers separating mental health care from physical health care. The company partners with health insurers to facilitate referrals from primary care doctors to in-network mental health professionals.

“Quartet is solving for a problem we wish didn’t exist,” said Robert Accordino, MD, a psychiatrist at Massachusetts General Hospital and Quartet’s chief of behavioral health. “The problem is there are huge barriers for patients to get the mental health care they need.” The obstacles include the stigma attached to mental health treatment and the shortage of mental health providers — a problem that is heightened for patients who rely on safety-net providers. Among Californians with a mental illness, more than 60% reported not having received any mental health services in the past year.

Quartet has created an app that operates within the electronic health record used by primary care doctors. A doctor who believes a patient would be helped by seeing a psychiatrist or mental health therapist can refer the patient to Quartet with the app. A Quartet care manager will then phone the patient and match them with an appropriate mental health professional known to be available within the insurance network.

Making Sure Patients and Doctors Don’t Give Up

This sounds simple, but it helps avert a common set of problems, Accordino says. Typically, when a patient and doctor agree the patient needs a psychiatrist or therapist, “the primary care doctor would tell them to call the number on back of their insurance card or have someone in the office make those calls,” Accordino said. That can lead to a frustrating process of trying to figure out who’s available in the patient’s provider network. It requires multiple calls and waits for callbacks, especially because most mental health professionals aren’t taking new patients.

Quartet sidesteps these frustrations and reduces the chances that the patient or doctor’s office will give up and the patient won’t get the needed help. Sometimes, neither a patient nor an overworked doctor recognizes that the patient could benefit from seeing a mental health professional. Quartet uses a machine-learning process to identify such patients by reviewing claims data on all treatments. The algorithm looks for patterns of health care use that correlate with untreated mental or emotional disorders. That information is then communicated to the patient’s primary care doctor.

“Do you think, Doctor, that this is a patient who might benefit from mental health care?” Quartet might message the doctor, Accordino said. “In the last six months the patient has visited the ED three times with chest pain, had a negative medical work-up, and was not having a heart attack. Could it be underlying anxiety?” This, Accordino says, “is where data analytics come in.”

Quartet is working with insurers and health systems in several regions to develop the technology and approach. In California, all primary care doctors working for Sutter Health in the Sacramento area, along with a growing number of mental health professionals in the network, are using the technology. The company is studying participating patients to see if they are reducing ED visits, being hospitalized less, and otherwise benefiting. Insurers and health systems hope Quartet can save them money. That would have an important impact in the safety net. Mental illness is more than twice as prevalent among Medicaid enrollees as in the general population, and the technology could make a difference.

So far, Accordino said, the company has seen “statistically significant cost reductions” with “select cohorts of patients.” He declined to disclose details.

Dangerous Asthma Flare-Ups

When Rajan Merchant, MD, was diagnosed 12 years ago with high cholesterol and was advised to take medications to keep it under control, he struggled to remember his daily pill, and frequently forgot. Then he got a smartphone and began setting a daily alert to remind himself. Today, as an allergy and asthma specialist with Dignity Health, a 41-hospital health network based in San Francisco, he’s helping patients with asthma employ a similar approach. This one uses technology developed by Madison, Wisconsin-based Propeller Health.

Propeller’s strategy is to attach sensors to the inhaler devices that patients use to control their asthma symptoms. The sensor sends a signal when the inhaler is used. If patients forget to take a dose, an email or text message reminds them 15 minutes later. They may also get a less discreet nudge when the sensor itself starts beeping. The goal: to help asthma patients manage their symptoms so that they don’t end up in the ED or admitted as an inpatient. Many ED visits might be prevented if people with asthma could better control their symptoms and avoid triggers that cause flare-ups.

Most people with severe chronic asthma take medications once or twice a day, with or without symptoms, to keep the disease in check. The most commonly used drugs are inhaled corticosteroids. Other types are used as adjuncts. If people start wheezing or have trouble breathing, they may use an inhaled, potent rescue medication for short-term relief.

Propeller Health, which calls itself a digital therapeutics company, reasons that one factor that causes flare-ups, triggers people to reach for rescue medications, and sometimes go to the ED, is human error. People simply forget to take their routine medication when they should have. Other patients may be under-treated or take ineffective doses.

Research and professional guidelines have long said that consistently taking the most effective medication on an appropriate schedule is key to helping people control their asthma and stay out of the ED. But asthma management is complicated, and tracking patients’ medication use over time helps doctors get a clearer picture. The Propeller system sends information to a clearinghouse that keeps a history of each patient’s pattern of usage: When are they taking the daily controller medication? How often do they need to take rescue medication?

Before using Propeller, when asthma patients would come in every three or six months for a routine appointment, most wouldn’t be able to remember their precise usage history. “People just can’t recall how many times, for instance, they used their rescue inhaler in the last 30 days,” Merchant says. “It’s never an accurate number.”

At its best, this kind of technology can track medication use and the progression of a chronic disease and help doctors and patients communicate more effectively, said Hsia.

Opening the Door to a Conversation

“We may provide medications assuming patients are taking them as prescribed or think we’re tailoring medications to patients based on their use — and it turns out that’s not actually the case,” she said. “If a patient is not taking a medication, maybe there’s a reason that we need to know. That opens a door to having a conversation. Is it a pharmacy issue? Is it an insurance issue?”

Dignity clinicians in and around Sacramento began working with the technology about five years ago and now use it with 600 asthma patients. They have also conducted clinical trials measuring its effectiveness. The most recent, published in December, followed 224 adult and child asthma patients for a year before they started using the Propeller technology and then for a year more. They measured use of the rescue medication, visits to the ED, and hospital admissions.

The researchers found ED visits fell from 11.6 per 100 patients in the year before using the Propeller technology to 5.4 during one year of use. Hospital admissions declined from 1.8 to 0.4 per 100 patients. The use of rescue medications also dropped. In the first week when medication use was monitored by Propeller, patients puffed on their rescue inhalers an average of 0.68 times a day. By week 52, that had dropped to 0.16 times a day.

Merchant says the benefits are so clear that the use of Propeller has been expanded to Dignity Health facilities in Phoenix, Arizona, and Ventura County, California, and will be rolled out to all Dignity asthma patients. Eventually patients with the Catholic Health Initiatives system may also benefit, because it merged with Dignity in February to form a new nonprofit health system called CommonSpirit Health that has 142 hospitals, 700 care sites, and nearly $30 billion in annual revenue. Propeller was acquired in January by ResMed Inc., a San Diego-based company that makes medical equipment, including sleep apnea masks for people with sleep-disordered breathing.

Over time, Merchant said, the technology will become the standard of care for all health systems managing respiratory disease patients. Merchant said he knows that in health care, change takes time, but he hopes it will be sooner rather than later.

Rob Waters

Rob Waters is an award-winning health and science writer whose articles have appeared in BusinessWeek, Mother Jones, Stat, San Francisco magazine, the San Francisco Chronicle Sunday magazine, the Los Angeles Times, and many other publications. He is the founding editor of MindSite, a digital publication covering mental health news scheduled to launch in fall 2021.

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