Assesses emergency department (ED) utilization among commercial (18 and older) and Medicare (18 and older) health plan members. Plans report observed rates of ED use and a predicted rate of ED use based on the health of the member population. The observed and expected rates are used to calculate a calibrated observed-to-expected ratio that assesses whether plans had more, the same or less emergency department visits than expected, while accounting for incremental improvements across all plans over time. The observed-to-expected ratio is multiplied by the emergency department visit rate across all health plans to produce a risk-standardized rate which allows for national comparison.
Why It Matters
ED visits are a high-intensity service and a cost burden on the health care system, as well as on patients. Some ED events may be attributed to preventable or treatable conditions. A high rate of ED utilization may indicate poor care management, inadequate access to care or poor patient choices, resulting in ED visits that could be prevented.1,2 Plans can ensure that members receive appropriate, coordinated primary care to address preventable ED visits.
Results – National Averages
Emergency Department Utilization Total Rate
| Measure Year | Commerical HMO | Commercial PPO | Medicare HMO | Medicare PPO |
|---|---|---|---|---|
| 2022 | 156.9 | 150.5 | 326.4 | 307.5 |
| 2021 | 156.2 | 147.4 | 309 | 294.1 |
| 2020 | - | - | - | - |
| 2019 | 195.3 | 190.3 | § | § |
| 2018 | 192.1 | 187.8 | 507.9 | 479.2 |
*Lower rates signify better performance.
§ Not available due to CMS suspension of data reporting during COVID-19 pandemic.
This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.
Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via my.ncqa.org for analysis that accounts for trend breaks.
References
- Dowd, B., M. Karmarker, T. Swenson, et al. 2014. “Emergency department utilization as a measure of physician performance.” American Journal of Medical Quality 29 (2), 135–43. http://ajm.sagepub.com/content/29/2/135.long
- Agency for Healthcare Research and Quality. 2015. Measures of Care Coordination: Preventable Emergency Department Visits. Accessed at https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html