The Prescription for Lowering Health Care Costs? Look at What Doctors Do

As US companies and consumers struggle to keep up with surging health care costs, new research suggests a way to save billions in medical expenses each year: Reduce emergency room visits by giving patients better access to prescription medications.

After all, emergency department (ED) visits account for a significant portion of US health care costs—more than 12 percent—but many of those costly ED visits could be avoided if people weren’t rushing to hospitals when they could receive care in less expensive ways, research by Harvard Business School Professor Amitabh Chandra shows.

In an extensive analysis of more than 21 million Medicare patients, Chandra found that doctors and their spouses make 20 percent fewer visits to the emergency department than the general public. Physicians are able to avoid emergency rooms more often, not because of their medical know-how, but because they can write prescriptions for themselves and their spouses, whereas the average person—and even nurses—cannot, according to Chandra’s working paper, “Expert Patients’ Use of Avoidable Health Care.”

“This is pointing to structural problems in how we’re building our health care system,” Chandra says. “Prescriptions are something that emergency rooms deliver that people are not able to get quickly enough.”

The research comes as the US faces increased economic uncertainty and as companies continue to grapple with soaring health care expenses, with 2025 projected to be the third consecutive year in which health care costs for employers are expected to rise by more than 5 percent.

Chandra—the Henry and Allison McCance Family Professor of Business Administration at HBS and the Ethel Zimmerman Wiener Professor of Public Policy at Harvard’s John F. Kennedy School of Government—conducted the research with Pragya Kakani, assistant professor at Weill Cornell Medical College, and Simone Matecna, a doctoral student at the Harvard Kenneth C. Griffin Graduate School of Arts and Sciences.

Why nurses don’t avoid the ED

The cost of avoidable ED visits is a huge problem: A 2017 study, the most recent year for which reliable data is available, put the number at $60 billion. Costs have only risen since then, and studies have shown that as insurance coverage expands, so does emergency room use.

The research team decided to explore whether “expert” patients—physicians, nurses, and their spouses—use the ED less frequently for medical care that could be obtained in other settings. This includes care sought for urinary tract infections, back pain, and asthma flareups.

To control for socioeconomic factors, the researchers compared ED use by physicians and their family members to a specific Medicare population of attorneys and their families who also earned high salaries between 2006 and 2017. They also compared nurses and their families to the general Medicare population.

While doctors made about 25 percent fewer trips to the ED that could have been avoided, nurses—who also have substantial training and experience in treating injuries and illnesses—only made about 7 percent fewer avoidable visits.

“We were really puzzled by the difference between physician and nurse households because nurses have a lot of medical knowledge,” Chandra says.

The power of prescribing

As the researchers looked more closely at the data, they realized that it wasn’t medical knowledge that prevented ED visits. Instead, what made the difference was that physicians were able to write prescriptions, while nurses were not. What’s more, physicians frequently wrote prescriptions for themselves and their families: 44 percent of doctors self-prescribed drugs, and 33 percent of spouses received prescriptions from their physician spouses.

As it turned out, the kinds of medications most often self- or spouse-prescribed—antibiotics, non-opioid pain and anti-inflammatory medicines, and corticosteroids—were the same types of prescriptions most often prescribed for nurses and the general patient population after avoidable visits to the ED.

“This suggests that this ability to self-prescribe may be behind the reduction in avoidable ED visits among physicians and their spouses,” Kakani says.

Further support that easy access to prescriptions was key: The data showed that if a prescription wasn’t the answer to a health problem, doctors’ use of avoidable visits wasn’t dramatically different than the average patient.

How to reduce avoidable ED visits

Although the researchers studied Medicare patients, Chandra says they’d expect to find similar results among the commercially insured population. “In the commercial population, [the difference in avoidable ED visits] might be larger,” Chandra says. “There are no babies or children who are covered by Medicare, so If it’s a treatment for a coughing baby that could be prescribed and picked up, say after a telehealth visit, they could avoid some babies coming in [to the ED] and free up resources for other babies.”

As policymakers, insurers, and others consider ways to expand access to prescriptions outside of the ED, Chandra says “rapid and easy is key,” particularly for patients with urgent symptoms. Possible options include:

• An increase in retail and urgent care clinics, lower-acuity settings where care costs much less than in the ED.

• More widespread adoption of telehealth visits, which can save money by delivering care more efficiently for conditions that don’t require in-person visits.

• Working with states to expand the prescribing powers of nurses and pharmacists and setting up hotlines to quickly provide medications.

• Companies can work with their insurance providers to expand access to ED-like services for their employees, or even contract directly with a growing number of businesses that provide such services, like Amazon’s One Medical.

Given the challenges patients have getting appointments with their primary care providers, Chandra says simply saying that patients should see their doctors instead of going to the ED is not going to work. What also won’t work, he says, is simply offering more medical information to patients.

“Don’t spend time on patient education efforts—that’s unlikely to work” Chandra says. “Unless we think we’re trying to get people to have more medical knowledge than nurses.”

Image: Ariana Cohen-Halberstam with assets from AdobeStock.