ER High Utilizers: It’s Not the Plan, It’s the Payment Model

TJ Bullock | March 11th, 2026

If you’ve spent more than five minutes looking at your company’s healthcare spend, you’ve seen it: ER claims that look like a leaky faucet… connected to a firehose.

Two stats tell the whole story:

• 70% of hospital admissions start in the ER. (That’s the front door to the biggest claims.)
• Only ~13% of ER visits are true emergencies. (Most of the time, it’s “urgent” — not “ambulance.”)

So no, this isn’t an employee “common sense” problem. It’s a system design problem.

At Bullock & Associates, we say it all the time: It’s not your plan, it’s how you’re paying for it.

The “High Utilizer” Profile (AKA: Who’s Actually Driving Repeat ER Use)

High ER utilizers usually aren’t thrill-seekers who love fluorescent lighting. They’re people with predictable patterns:

• Mental Health: anxiety/panic, depression, bipolar—when it spikes after hours, the ER becomes the default.
• Tobacco Use: it’s gasoline on respiratory issues and chronic inflammation. Small problem → fast escalation.
• Chronic Disease: COPD/asthma, diabetes, heart disease, migraines, chronic pain—especially when conditions stack.

This is the group where “a simple ER visit” turns into “surprise admission,” and suddenly your plan has a six-figure storyline.

Why Fee-For-Service Keeps Feeding the ER

Fee-For-Service (FFS) medicine pays for volume, not fixing.
That’s how you get:

• Short visits (8–15 minutes)
• Long waits (weeks to get in)
• Zero access when life happens (nights/weekends = good luck)

When someone with anxiety + tobacco history + COPD starts wheezing at 7:00 PM, they don’t need a lecture. They need a clinician. Now. The ER wins by default.

The Plug for the Leak: Non‑FFS Primary Care (Like DPC)

Non‑FFS models (like Direct Primary Care) flip the incentive:

• pay for the relationship
• build access (same/next-day, texting/calls)
• spend time upfront so you don’t pay for chaos later

That’s the “plug.” Not a bigger deductible. Not a stern email about “appropriate settings of care.”

If you want fewer admissions, you don’t start with the ER.
You start with the payment model that’s quietly steering people there.

Ready to find where your ER overuse is actually coming from—and what model fixes it?

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Making complicated simple.

#UBA #NABIP #employeebenefits #HealthInsurance #ERUtilization #CostContainment #DirectPrimaryCare

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