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Case Study

Administrative Services Only (ASO) plan achieves $162 reduction in ER costs per member per year (PMPY)

By June 15, 2021July 13th, 2021No Comments

Fast, simple approach targets behavior to help ASO plan decrease avoidable ER visits

In 2015, a large regional health plan engaged Softheon to address a problem that many plans struggle with: avoidable ER visits.

According to a 2019 study by the UnitedHealth Group, in a population of patients with health insurance, as many as two-thirds of the U.S.’s emergency room (ER) visits are avoidable, and the costs of these avoidable ER visits are on average 12 times higher than being treated at a physician’s office and 10 times higher than being treated at an urgent care center. ​​

The most troubling aspect of this study may be that the healthcare marketplace has known about the high costs of avoidable ER visits for many years. So, why haven’t health insurers been able to successfully discourage members’ unnecessary ER utilization? Some insurers have tried unpopular policies that deny payment for ER visits that didn’t involve issues posing a serious risk to health. This strategy, though, earns only negative press and lost goodwill, as this NY Times article shows.