What counts as an avoidable ER visit
An avoidable (or "potentially avoidable") ER visit is one where the presenting complaint could have been treated safely in a lower-acuity setting — urgent care, a physician's office, telehealth, or the patient's own home. Classic examples: sore throat, earache, urinary tract infection symptoms, mild fever, sprains, minor cuts, rashes, cough and cold complaints.
Published estimates of the avoidable share vary with methodology, but analyses from payers and health-services researchers have repeatedly landed in the range of two-thirds of all ER visits being potentially avoidable or treatable elsewhere. Even conservative methodologies that only count clearly non-emergent diagnoses land on a substantial double-digit percentage. Whatever number you adopt, it multiplies against one of the most expensive per-episode line items in your claims data — see what an ER visit costs.
Running the math on your own plan
You need three inputs, all available from your TPA's reporting:
- ER visits per 1,000 members per year. National benchmarks often land near 150–200 per 1,000; your plan's actual number is in your utilization report.
- Average allowed amount per ER visit for your plan — commonly $1,200–$2,900+.
- An avoidable-share assumption. Choose your own conviction level: 30% is conservative, two-thirds matches the broader published estimates.
The arithmetic: a 1,000-member plan with 180 ER visits at a $1,800 average allowed amount is spending $324,000 a year in the emergency department. If even a third of those visits could resolve elsewhere, roughly $108,000 of annual claims spend is in play — before counting the urgent care claims, absenteeism, and downstream imaging that ride along with facility-based care. At the two-thirds estimate, the number more than doubles.
This is also where high-cost claimant analysis connects: frequent ER utilizers are often unmanaged chronic conditions announcing themselves. Redirection plus physician follow-up catches some of those cases earlier.
Why members use the ER when they "shouldn't"
Claims data shows the what; benefit design has to answer the why. Members choose the ER for avoidable complaints for predictable reasons:
- Timing. Symptoms spike at night and on weekends, when offices are closed and urgent care is closing.
- Uncertainty. "Is this serious?" is genuinely hard to answer at home — and the ER is the only door that never says "we can't tell from here."
- Diagnostics. Members correctly intuit that a possible fracture or a feverish child may need an X-ray or a test, and they pick the setting guaranteed to have them.
- Access gaps. No established primary care, no transportation options, no childcare for a waiting room.
Any redirection strategy that ignores these reasons — hotline posters, cost-sharing penalties, "think twice" campaigns — reliably underperforms, because it asks members to accept less capability at their moment of maximum worry.
The benefit design that actually redirects visits
The alternative has to match the ER on the things members actually go there for: physician judgment, diagnostics, and always-open access. That's the design brief behind EZaccessMD:
- 24/7 telehealth with a board-certified physician calling back within the hour — the "is this serious?" question answered immediately.
- In-home diagnostics when the case needs evidence: a medical technician dispatched to the home with portable X-ray, ultrasound, EKG, lab-draw, and rapid-test equipment, with radiologist reads and physician follow-up.
- $0 member copay, so the cheapest option for the plan is also the cheapest option for the member — at the moment of decision, there is no reason left to default to the emergency department.
- Household coverage, because pediatric fevers are a disproportionate share of avoidable after-hours visits.
Employers and brokers can put their own census through the ROI calculator, review modeled plan savings, or compare approaches on the comparison hub. The broader strategic context lives in our healthcare cost containment guide.