- Most frequent users of the emergency department have serious medical problems that can only be treated in an emergency department.[i]
- Most frequent users of the emergency department have a regular source of medical care and health insurance.[ii]
- Emergency departments are the safety net for everyone, especially these most vulnerable patients.
- Emergency physicians are committed to helping frequent users obtain access to ongoing care in their communities when appropriate and available.
- Diverting frequent users of the emergency department to other sources of care is not likely to reduce costs significantly.
Who are typical frequent users of the emergency department?
Many frequent users are people with serious chronic illnesses like cancer or heart problems or sickle cell anemia. These people have diseases that are not necessarily predictable and may require medical care on days they can’t get in to see their regular doctors. Or their regular doctors don’t have the equipment or medicine to help them. According to a study published in 2013 in Health Affairs, “the overwhelming majority of frequent users have only episodic periods of high ED use, instead of consistent use over multiple years.”[iii]
Media reports have focused on the subset of frequent users who have severe social issues that aren’t being met, such as homelessness, drug addiction or psychiatric illness, but these patients are in the minority and they have no place else to go.[iv] Most of these patients are not admitted to the hospital, which is really where the majority of health care expenses are incurred.
How much do frequent users cost the health care system?
Definitions of what constitutes a frequent user vary. An Annals of Emergency Medicine study reported that frequent users make up between 4.5 and 8 percent of all emergency patients and are responsible for 21 to 28 percent of all emergency department visits.[v] Since emergency care itself only constitutes approximately 4 percent of all health care spending, the amount allocated to frequent users is not significant.
Why is there so much focus on these patients?
People want easy solutions to complex problems. Policymakers and states – particularly state Medicaid offices – are looking to reduce health care costs. Emergency physicians are committed to this as well but many of the sources of rising health care costs are not in the emergency department. The largest sources of health care waste are unnecessary services[vi], inefficient delivery, administrative costs, missed prevention opportunities and fraud.[vii] Policymakers and health insurers know that fixes to these problems won’t come quickly, so it is easier to “demonize” patients who are unable to get care when they need it.
Would getting frequent users ongoing primary care keep them out of the ER?
It likely will help, but many of these patients already have regular, ongoing primary care. They have illnesses that require complicated interventions that can only be found in the emergency department. A recent study from Massachusetts General Hospital found that frequent users were NOT more likely to make emergency visits that could have been handled by a primary care physician.[viii]
How much of a role does untreated mental illness play in bringing frequent users to the ER?
Frequent users have high odds of coming to the ER for mental health or substance abuse-related reasons, which suggests that the dearth of community resources is contributing to frequent emergency visits for some patients.[ix]
The lack of resources for mental health emergencies has been well-documented, and every emergency physician in the country can talk about the difficulties of treating psychiatric emergencies in a system that isn’t equipped to handle them. A study from San Diego found that occasional and frequent psychiatric patients tend to visit more hospitals compared to non-psychiatric patients.[x] It shows how great the unmet needs of these patients are.
Some frequent users are just doctor shopping, trying to get drugs, right?
Some drug abusers visit multiple health care facilities in order to obtain drugs, including different physician offices, clinics and ERs. Without knowing a patient’s history, emergency physicians cannot always determine if a patient has legitimate medical needs or is just drug-seeking. Many drug seekers have real pain. An emergency physician’s first responsibility is to the patient and to relieve suffering.
Emergency physicians are not in law enforcement. That said, prescription monitoring programs can be very helpful. The CURES program in California and the eKASPER program in Kentucky allow emergency physicians to look up their patients to determine if they are habitual drug-seekers. According to the ACEP publication “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department,” the use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.
Are programs in place to manage frequent users so they don’t end up in the ER?
A work group in Washington State — made up of representatives from the state’s Medicaid office, hospital association, medical association and ACEP chapter — is implementing seven best practices to approach frequent Medicaid users of the ER. There was approximately $31 million in savings during the first year. Other states are experimenting with providing housing to homeless populations to help keep that subset of Medicaid patients out of emergency departments. A paper published in 2013 in the New England Journal of Medicine stated that: “Reforms such as care coordination models and patient-centered medical homes are necessary but insufficient for homeless populations with complex problems. Pairing such reforms with supportive housing is more likely to result in lasting health improvements and reduced costs.”[xi]
[i] Annals of Emergency Medicine, “Characteristics of Repeat Emergency Department Users at a University Medical Center,” October 2012, Vol. 60, Nov 48. Miller, SE; Ghaemmaghami, CA; O’Connor, RE/University of Virginia, Charlottesville, VA.
[ii] Annals of Emergency Medicine, “Frequent Users of Emergency Departments: The Myths, the Data and the Policy Implications,” LaCalle, et al., 2010; and Annals of Emergency Medicine, “Characteristics of Frequent Users of Emergency Departments,” Hunt et al., 2006.
[iii] Health Affairs, “Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden of Disease,” Billings, Raven, 2013. http://content.healthaffairs.org/content/32/12/2099.abstract
[iv] Academic Emergency Medicine, “Analysis of Costs, Length of Stay and Utilization of Emergency Department Services by Frequent Users: Implications for Health Policy,” Jennifer Prah Ruger, et al. 2004.
[v] Annals of Emergency Medicine, “Frequent Users of Emergency Departments: The Myths, the Data and the Policy Implications,” LaCalle, et al., 2010.
[vii] Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (2012) Institute of Medicine. http://books.nap.edu/openbook.php?record_id=13444&page=9
[viii] Annals of Emergency Medicine, “Frequent Users of the Emergency Department: Do They Make Visits That Can Be Addressed in a Primary Care Setting”, Liu et al., 2012.
[ix] Annals of Emergency Medicine, “Frequent Users of the Emergency Department: Do They Make Visits That Can Be Addressed in a Primary Care Setting”, Liu et al., 2012.
[x] Annals of Emergency Medicine, “Multiple Hospital Emergency Department Visits Among ‘Frequent Flyer’ Patients with a Psychiatric-Associated Discharge Diagnosis,” Brennan et al. 2012.