To succeed in value-based care and achieve shared savings, accountable care organizations (ACOs) must deliver high-quality care while effectively managing total healthcare expenditures. Emergency department (ED) utilization represents a key cost driver, accounting for nearly 5% of total U.S. healthcare spending and continuing to rise (Scott et al., 2021). The scale of the opportunity is significant; research indicates that up to 37% of ED visits are nonurgent, meaning that delaying care would not increase the risk of adverse outcomes (Uscher-Pines et al., 2013).
The cost implications of nonurgent ED visits are substantial. Treating the same diagnosis in the ED is often 3–10 times more expensive than in an urgent care center, and even more costly compared to primary care, retail clinics, or telehealth (Ho et al., 2016; Mehrotra et al., 2009). For ACOs managing population health across thousands of attributed lives, particularly in communities with limited access to primary care, proactively addressing the root causes of avoidable ED utilization is essential for maintaining quality performance and meeting financial targets.
The financial impact is compelling: for a typical ACO managing 10,000 attributed lives, even small improvements in connecting patients with a primary care provider for appropriate conditions can generate significant returns. Each prevented emergency room visit can save $1,500-$3,000 in direct costs while contributing to improved quality scores that unlock additional shared savings. This article explores how high ED utilization impacts value-based care outcomes and outlines evidence-based strategies ACO leaders can leverage to reduce avoidable and nonurgent ED visits and optimize shared savings performance.
The Value-Based Care Impact: How ED Utilization Threatens ACO Financial Performance
Emergency department (ED) costs continue to rise, creating significant challenges for the financial performance of Accountable Care Organizations (ACOs). In 2021, there were 107.4 million ED visits that did not result in admissions, representing approximately $80.3 billion in spending. In 2019, the average cost of low-acuity ED care was $1,716 per visit, nearly 10 times higher than the average cost of an urgent care visit at $178 (Roemer, 2024).
These cost differentials directly impact ACO shared savings calculations. When beneficiaries with manageable conditions default to emergency care due to access barriers or care coordination gaps, the resulting utilization patterns can eliminate shared savings opportunities while negatively affecting quality measure performance.
Addressing Root Causes: Primary Care Access, Social Risk, and Behavioral Health Integration
Primary Care Access
Primary care access limitations represent the most direct driver of inappropriate ED utilization. When patients cannot secure timely, convenient appointments with a primary care provider, patients may seek care in an emergency department setting, or nonurgent conditions may escalate to emergency-level presentations. ACOs implementing same-day access programs, extended hours, and urgent care partnerships within their provider networks have seen reductions in non-urgent ED visits while improving primary care access quality measures.
Transportation barriers
Transportation barriers significantly impact emergency department (ED) utilization, particularly among individuals with chronic conditions and those from socioeconomically disadvantaged backgrounds.
Research has shown that adults who experienced delays in care due to lack of transportation had a higher likelihood of ED visits and increased mortality risk (Jiang et al., 2023). Individuals with chronic conditions such as diabetes or hypertension are more likely to face transportation challenges, leading to delayed or missed care, which often results in preventable ED visits. A study in North Carolina showed that approximately one-third of high-frequency patients reported transportation barriers, contributing to late arrivals and missed appointments (Cochran et al., 2022).
Addressing transportation barriers is crucial for improving healthcare access and reducing unnecessary ED utilization. Implementing solutions such as expanded transportation services and better coordination between healthcare and transportation providers can mitigate these challenges and enhance patient outcomes.
Food insecurity
Food insecurity is strongly associated with higher emergency department utilization. Studies show that individuals experiencing food insecurity are significantly more likely to be frequent ED users, with one urban hospital study finding that 62.8% of frequent ED visitors were food insecure compared to 45.4% of non-frequent users (Doran et al., 2022). National data also demonstrate that food insecurity predicts higher ED visits, hospitalizations, and overall healthcare expenditures (Berkowitz et al., 2018), with severity of food insecurity linked to up to double the rate of pain-driven ED visits (Men et al., 2022).
Medication Access and Adherence
Similarly, poor medication access and adherence drive preventable ED utilization. Adults with chronic diseases such as diabetes, hypertension, and congestive heart failure experience more ED visits and hospitalizations when adherence is low (Simon-Tuval et al., 2022; Hope et al. 2004). Patients with COPD who maintained high adherence had significantly fewer ED visits (44.6% vs. 57.5%) and hospitalizations (Alghamdi et al., 2023). Barriers such as medication cost, affecting over 9 million U.S. adults, and the presence of “pharmacy deserts” in nearly 46% of U.S. counties further exacerbate these risks (Mykyta and Cohen, 2023; OSU Wexner Medical Center, 2024).
Housing instability
Housing instability is a significant social determinant of health that contributes to increased emergency department utilization. Individuals experiencing homelessness or unstable housing often face challenges accessing primary care and managing chronic health conditions, leading them to rely on the ED for both urgent and non-urgent needs (Kushel et al., 2006). Research shows that people with housing instability have higher rates of ED visits and hospitalizations compared with those in stable housing, largely due to unmanaged medical conditions, mental health needs, and limited access to preventive services (Baggett et al., 2010; Hwang et al., 2011). Interventions that address housing insecurity, such as supportive housing programs, medical respite care, and partnerships between healthcare systems and housing organizations, have been associated with reductions in ED visits and improved health outcomes (Baggett et al., 2010).
Behavioral Health
Behavioral health conditions represent one of the highest-impact opportunities for ACOs to improve both quality metrics and cost performance. Patients with mental health and substance use disorders frequently generate high ED utilization patterns that significantly threaten value-based care success.
The Medicare Shared Savings Program specifically tracks depression screening and follow-up, recognizing behavioral health’s critical role in population health management. ACOs failing to identify and manage behavioral health conditions underperform across multiple quality domains while experiencing higher-than-expected costs.
Substance use disorders create particularly challenging patterns, with patients cycling through EDs for complications without receiving definitive addiction treatment. Each untreated substance use disorder can generate $15,000-$30,000 in annual costs while contributing to poor performance on multiple quality measures.
Successful ACOs implement collaborative care models integrating behavioral health within primary care settings, deploying social work teams to address underlying social determinants. Crisis intervention programs providing 24/7 mental health access have demonstrated effectiveness, preventing costly ED visits while improving patient satisfaction scores.
Identifying High Emergency Department Utilizers: Definitions and Analytics
Differing Definitions of High ED Utilization
The identification of high emergency department utilizers begins with establishing clear, consistent definitions that can guide both analysis and intervention efforts. However, significant variation exists in how healthcare organizations and researchers define high utilization, creating challenges for benchmarking and program development.
The most commonly used threshold defines high utilizers as patients with four or more ED visits within a 12-month period (Althaus et al., 2011). This definition, while widely adopted, represents somewhat arbitrary criteria that may not capture the full spectrum of concerning utilization patterns. Some organizations use alternative thresholds, such as six visits per year or three visits within a six-month period, depending on their specific population characteristics and organizational goals.
More sophisticated approaches incorporate multiple dimensions beyond visit frequency, including total costs, acuity levels, and time intervals between visits. These multidimensional definitions provide more nuanced understanding of utilization patterns but require more complex data systems and analytical capabilities to implement effectively.
Pediatric populations require distinct definitional approaches, as normal utilization patterns differ significantly from adult populations. Similarly, certain patient populations, such as those with chronic dialysis needs or complex chronic conditions, may have legitimately high ED utilization rates that should not be categorized alongside inappropriate utilization.
Role of Analytics in Finding High Utilizing Patients
Advanced analytics are playing an increasingly important role in identifying patients at risk of high emergency department (ED) utilization before problematic patterns become entrenched. Predictive modeling approaches leverage historical utilization data, clinical characteristics, and social determinants of health to identify patients who are likely to become high utilizers. By analyzing large and complex datasets, these models can detect subtle risk patterns that may not be apparent through traditional clinical assessment, allowing healthcare organizations to implement proactive interventions rather than reacting to crises after they occur.
These predictive models can incorporate diverse data sources, including claims data, electronic health records, and geographic data, creating a comprehensive view of patient risk factors. When combined with risk stratification algorithms, predictive analytics can categorize high utilizers according to the underlying drivers of their ED use, such as chronic medical conditions, behavioral health challenges, or social and environmental barriers. This segmentation enables care teams to develop tailored, patient-centered interventions that address the specific factors contributing to each individual’s high utilization patterns.
By identifying high-risk patients early and targeting interventions appropriately, healthcare organizations can improve patient outcomes, reduce unnecessary ED visits, and optimize the allocation of care management resources. Overall, predictive modeling and risk stratification provide a powerful framework for proactive population health management, supporting more efficient, effective, and personalized approaches to managing high ED utilization.
Evidence-Based Strategies for Reducing ED Utilization
Successful accountable care organizations (ACOs) achieve both lower emergency department (ED) utilization and higher quality performance by implementing comprehensive, multi-faceted strategies. The most effective approaches combine proactive clinical care management with targeted quality improvement initiatives that support value-based care goals. By integrating interventions such as improved primary care access, complex care management, transitional care programs, and community-based support, ACOs can prevent unnecessary ED visits while simultaneously improving patient outcomes and meeting key quality metrics.
Primary Care Access
Evidence shows that improved access to primary care is associated with reduced emergency department utilization. Patients with timely access to primary care, including same-day appointments, extended hours, and continuity with a usual provider, are less likely to use the ED for non-urgent issues (Hong et al., 2020). The Comprehensive Primary Care (CPC) Initiative showed that practices providing enhanced access experienced slower growth in all-cause ED visits and primary care–substitutable ED visits, as well as reduced urgent care utilization (Hong et al., 2020). Similarly, embedding urgent care services within primary care networks has been shown to divert non-emergent cases from the ED while maintaining continuity of care (Allen et al., 2021).
Transitional care management
Transitional care management programs have proven particularly effective for ACOs managing high-risk populations. These programs provide intensive support during the critical 30-day period following hospital discharge, reducing both ED visits and readmissions while improving performance on care transitions measures that are crucial for shared savings eligibility. ACOs implementing robust transitional care programs typically see 20-30% reductions in 30-day readmissions and corresponding decreases in subsequent ED utilization (Burke et al., 2014).
Complex care management interventions
Complex care management (CCM) can effectively reduce emergency department (ED) utilization, particularly among high-risk populations. A systematic review and meta-analysis indicated that CCM interventions led to a significant reduction in ED visits, especially when delivered by multidisciplinary teams and tailored to individual patient needs (Stokes et al., 2015). Additionally, intensive case management programs for frequent ED users reduced ED visits by 83% over six months, demonstrating substantial impact on high-utilizing patients (Grover et al., 2010). Evidence from Medicare populations shows that care coordination, a core component of CCM, reduces hospitalizations and improves quality of care without increasing total healthcare expenditures (Peikes et al., 2009). These findings suggest that CCM and structured care coordination programs can be effective strategies for decreasing unnecessary ED visits and improving patient outcomes.
Technology-enabled interventions
Technology-enabled interventions, such as 24/7 nurse triage lines and virtual telehealth consultations, offer scalable approaches to reducing nonemergent ED utilization and align with ACO quality improvement objectives (Hong et al., 2020). These programs provide patients with timely access to clinical guidance from their primary care provider network, helping them determine appropriate care settings while documenting care coordination efforts that support quality reporting requirements. Virtual access solutions have been shown to be particularly effective for underserved populations who face transportation or scheduling barriers to traditional office visits, resulting in decreased ED visits for non-urgent conditions (Linet al., 2018).
Remote patient monitoring (RPM) can also help reduce unnecessary visits to the emergency department, especially for people with chronic health conditions or those recently discharged from the hospital. For example, a study of high-risk patients who used home digital monitoring found that their ED visits dropped significantly over three and six months compared to before the program (Po et al., 2024).
Community Health Workers and Community Partners
Community Health Workers (CHWs) and community partnerships have demonstrated effectiveness in reducing ED utilization, particularly among high-risk populations. A study involving patients with heart failure found that CHW interventions led to a 75% reduction in heart failure-related ED visits and an 89% decrease in related hospital readmissions (Vohra et al., 2020). Similarly, a program in rural Appalachia reported a 22% decrease in ED visits and a 30% reduction in hospitalizations after 12 months of CHW support (Crespo et al., 2020).
Community partnerships also play a significant role in reducing ED visits. For instance, a collaboration between public health and hospital systems in North Carolina focused on addressing food insecurity, resulted in decreased ED utilization among Medicaid-insured patients (Southerland et al., 2024). Additionally, a partnership in Virginia led to an 80% decrease in ED referrals from a homeless shelter after establishing an on-site clinic (Health Quality Innovation Network, 2024).
These findings suggest that integrating CHWs and fostering community partnerships can effectively reduce ED utilization by addressing underlying health and social issues through personalized care and community-based interventions.
The ACO Success Imperative: Complexity-Based Population Health Management
Accountable Care Organizations must move beyond traditional utilization management approaches that focus solely on visit reduction or cost containment. The most successful ACOs recognize that high ED utilization often reflects complex interactions between clinical conditions, social risk factors, and care delivery gaps that require sophisticated, targeted interventions aligned with value-based care objectives. Complexity-based population health management represents a strategic approach specifically designed for ACO success in a competitive shared savings environment. This methodology recognizes that effective interventions must address the multifaceted nature of excess healthcare utilization while directly supporting the quality measures and cost targets that determine ACO financial performance.
The evidence demonstrates that ACOs achieving consistent shared savings success implement comprehensive ED utilization management strategies that address both individual patient complexity and system-level care delivery improvements. These organizations understand that sustainable utilization reduction requires integrated approaches that simultaneously improve quality scores, reduce costs, and enhance patient satisfaction.
Furthermore, as ACO contracts increasingly incorporate downside risk and higher quality thresholds, effective ED utilization management becomes essential for organizational survival. ACOs that fail to address inappropriate utilization patterns face significant financial penalties under advanced payment models while struggling to achieve the quality benchmarks necessary for continued contract participation.
The integration of advanced analytics with clinical expertise enables ACOs to identify truly complex patients who require intensive care management versus those who might benefit from targeted access improvements or care coordination enhancements. This precision approach maximizes resource utilization efficiency while ensuring that interventions address the specific factors driving inappropriate ED utilization within each risk segment of the attributed population.
Successful ACOs also recognize that ED utilization management cannot operate in isolation from broader population health initiatives. The most effective programs integrate utilization reduction efforts with chronic disease management, preventive care initiatives, and care transitions improvements to create synergistic effects that support multiple quality measures simultaneously.
Driving High-Impact ED Reduction with Illustra Health
Illustra Health leverages advanced predictive modeling and complexity-based patient segmentation to pinpoint patients with impactable emergency department (ED) utilization. By integrating ED utilization classification with population-level insights, Illustra enables healthcare providers and care managers to focus interventions where they can deliver the greatest clinical and financial impact.
Recognizing that ED utilization is only one part of a larger care delivery challenge, Illustra goes beyond surface-level data to uncover patient-specific, actionable opportunities. This allows health systems and ACOs to design multi-faceted strategies that address the drivers of high utilization, from unmanaged chronic conditions to gaps in care coordination and social determinants of health.
Illustra Health’s population health experts partner directly with your organization to analyze your patient population, identify strategic opportunities, and guide the implementation of data-driven interventions. Through continuous performance monitoring and reporting on the metrics that matter, Illustra helps you measure results, adapt strategies, and sustain improvements over time.
By combining proven Johns Hopkins methodology with deep expertise in population health, Illustra Health delivers a command-center approach to complexity-based patient management. This model empowers care teams with both advanced analytics and strategic guidance to identify the most complex, high-need patients and deploy resources where they can have the greatest impact — improving outcomes, enhancing quality scores, and strengthening financial performance under value-based care arrangements.
Every healthcare organization faces unique population health challenges. Connect with Illustra Health to explore how their combination of advanced analytics, strategic insights, and operational expertise can help you implement a smarter, more targeted approach to managing complexity and reducing unnecessary ED utilization.
Conclusion
In value-based care, ACOs that successfully reduce unnecessary emergency department (ED) visits consistently achieve stronger clinical outcomes, higher quality scores, and meaningful cost savings across their patient populations. Addressing the multifaceted drivers of ED use, from limited primary care access and unmanaged chronic conditions to social determinants such as transportation, food insecurity, and housing instability, requires a coordinated, data-informed approach.
With the right tools and strategies, ACOs can move beyond reactive interventions to proactive population health management that reduces unnecessary ED visits, improves quality scores, and maximizes shared savings potential. By leveraging solutions like Illustra Health’s complexity-based patient management and predictive analytics, organizations are empowered to focus resources where they will have the greatest impact. The path forward is clear: smarter, more precise strategies that align clinical, operational, and financial goals are the key to sustainable success in value-based care.
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