According to the National Committee for Quality Assurance (NCQA), up to 60% of emergency department visits are non-urgent or potentially avoidable. The persistence of that figure points to a structural challenge for health plans. Emergency department utilization reflects inefficient network performance and unmanaged site-of-care decisions, not just access gaps.
For years, payer strategies have sought to address ED overuse by expanding access to alternative care options such as urgent care, telehealth, and nurse triage lines. These investments increase capacity, but they do not intervene when a member is choosing where to seek care. As a result, site-of-care selection remains largely unmanaged, and high-cost utilization persists across the population.
Payers embedding AI-enabled, physician-supervised primary care into their front door benefit from immediate care delivery and intelligent triage aligned to their clinical strategies. This results in a meaningful shift of non-urgent demand away from the emergency department, with care delivered earlier and within the appropriate clinical context.
ED utilization remains high because site-of-care decisions are made without consistent, real-time clinical input or context.
Existing access points are largely delayed, episodic, or dependent on scheduling. When symptoms emerge, members make site-of-care decisions in the moment, often without access to clinically reliable input. Under uncertainty, the emergency department is perceived as the safest option, even when the underlying concern can be safely addressed in a lower-acuity setting.
This pattern reveals an important distinction. Emergency department utilization is driven less by a shortage of access than by an absence of trusted, real-time clinical care at the point of need. When members cannot quickly determine whether a symptom is urgent, the rational choice is the setting that promises the broadest evaluation, even when its cost and intensity exceed what the situation requires. According to the Agency for Healthcare Research and Quality (AHRQ), treat-and-release ED visits alone account for approximately $80 billion in annual costs, underscoring how misaligned site-of-care decisions drive significant, avoidable spend.
Fragmentation in healthcare leaves care distributed across disconnected providers, systems, and encounters. Clinical decisions are routinely made without full visibility into a member's medical history, prior interactions across the care continuum, or ongoing and recently treated conditions.
When symptoms are evaluated in isolation, perceived risk increases. Both members and clinicians default to higher-acuity settings to avoid missing something serious, even when the clinical picture would not warrant it.
The result is a precautionary tilt that pushes utilization downward without improving outcomes. Without longitudinal clinical context about a member, escalation often becomes the path of least resistance.
Most care models are designed around discrete visits. There is no continuous clinical layer that follows members across interactions, meaning each medical concern is treated as a standalone event. Context resets, decision-making restarts, and the cumulative value of prior interactions is lost.
This episodic design results in inconsistent site-of-care selection and a structural reliance on the most expensive settings for issues that do not warrant emergency department escalation. It also limits a payer’s ability to manage ED utilization at the population level, since care occurs in isolated, disconnected encounters.
Health plans have invested heavily in urgent care, telehealth, and nurse lines. These channels expand the supply of care, but they share two consistent limitations:
Even with multiple alternatives available, members continue to default to the EDs when they are uncertain about how to interpret their symptoms. This is only exacerbated by consumer AI tools that often over-escalate, especially given that 8 out of 10 Americans use search engines or general-purpose LLMs for health information.
If ED utilization is driven by unmanaged decision-making, the intervention must occur before a member chooses where to seek care. Medical AI, operating with physician oversight, enables immediate care access at the point of need and at scale, particularly with solutions like Counsel that embed directly into a payer’s existing member experience.
When a health plan’s front door transforms from a navigation tool to a place where care actually happens, medical concerns get resolved in a timely manner. With Counsel, care pathways are tailored and aligned to a payer’s clinical protocols, provider directories, COEs, and ecosystem of health solutions. As a result, Counsel can deliver immediate, personalized advice and treatment and steer care in-network when additional follow-up is needed.
Many medical concerns, from new symptoms to lifestyle and chronic conditions, can be resolved through messaging-based care informed by longitudinal clinical context. This reduces unnecessary escalation and avoids ED visits driven by uncertainty. Solutions like Counsel also enable members to request labs, understand health results, get prescriptions, and more, enabling continuous support throughout a member’s health journey.
When an in-person evaluation is needed, members are directed to in-network resources or existing health solutions part of a payer’s ecosystem. This supports steerage to preferred providers and improves network efficiency.
Counsel serves as a clinically governed front door to care, embedding AI-enabled, physician-supervised primary care directly into a payer’s existing member portal or application. The model resolves 96% of member concerns without escalation to downstream care, an outcome made possible by context-aware AI triage, active physician oversight, and a strong foundation in responsible AI governance. In comparative testing, Counsel has also demonstrated a 24% reduction in unnecessary emergency department visits relative to consumer-facing AI tools, reflecting more appropriate triage and clear escalation pathways rather than restricted access.
This approach supports more predictable utilization patterns, reduces avoidable high-cost care, and strengthens overall network efficiency at the population level. Request a demo to see how Counsel’s healthcare payer solution can help your organization deploy a scalable and effective access point for care.
The Counsel Health editorial team is a multidisciplinary group of writers and editors dedicated to delivering clinically grounded, evidence-based health information. Their work is informed by real-world care delivery and guided by physician expertise, ensuring content is accurate, accessible, and trustworthy. By translating complex medical topics into clear, practical guidance, the team helps readers understand their health, explore care options, and make informed decisions in a rapidly evolving healthcare landscape.
Javier Monterrosa is a healthcare marketing leader who has spent his career driving growth across AI, metabolic health, interoperability, and EHR companies. He holds a Master’s in Analytics and has co-authored published research examining how strategic decisions shape business growth. Having grown up in Latin America, he is driven to partner with mission-driven teams committed to improving healthcare access and outcomes through responsible technology.
Our content is created for informational purposes and should not replace professional medical care. For personalized guidance, talk to a licensed physician. Learn more about our editorial standards and review process.
.png)
.png)
