A small but costly percentage of patients have a variety of reasons for frequent ED visits.
Stakeholders know that a small percentage of patients in the United States consume a disproportionate share of healthcare resources. At the high end, some are making as many as 20 visits a year or more to the hospital or emergency department (ED).
Known as “superusers” (about 1% of the population), they consume 21% of the nearly $1.3 trillion spent each year on healthcare in this country, according to an August 2013 statistical report by the Agency for Healthcare Research and Quality (AHRQ). To put it in perspective, 50% of Americans at the low end only use 2.8% of healthcare dollars in a year, according to AHRQ.
“Superusers are 1% of national, local and regional health expenditures,” says Jeffrey Brenner, MD, executive director and founder of the Camden Coalition of Healthcare Providers in New Jersey, a community organization. “In Camden, we spend about $108 billion a year on ED and hospital care, and the overutilizers are about 1% of that population, which is about 1,000 people. Yet, they account for about 30% of the total payment for hospitalization and ED care in Camden.”
Superusers appear in just about every American community. They are young and old, insured and uninsured, substance abuser and sober, mentally ill and mentally healthy, with and without a place to live, says Edward M. Castillo, PhD, MPH, faculty, University of California San Diego Medical Center, department of emergency medicine.
“The frequent user runs the gamut,” Dr. Castillo says. “Many are uninsured. Many have Medicare or Medicaid, and others have private health insurance. The risk factors for what makes a person a superuser will vary depending on the region you live, the community you live in and even how you look at superusers.”
Common conditions that bring them to the ED are chronic pain, heart disease, diabetes, kidney and liver diseases, respiratory diseases and substance abuse. But there are also many people using the emergency department for non-emergent issues such as sore throats, which should be treated by a primary care provider.
Most frequent users of emergency departments tend to suffer chronic illnesses that are not well controlled or have multiple psychosocial risk factors, such as mental illness, homelessness or substance abuse problems. Meanwhile, frequent users of inpatient care tend to be older, sicker and medically complicated patients with insurance, according to Dr. Brenner.
The commonality among superusers is that they often lack the social network that can help them coordinate their care after their release. In particular, many don’t have a regular physician that can provide ongoing primary care. When they need medical care, they turn to the community hospital-often the most expensive and least efficient type of healthcare for their needs.
Triage times ten
Healthcare in this country is a fragmented, episodic, uncoordinated and inefficient system, and the biggest hindrance to changing the system is often the system itself. Such fragmentation and inefficiency can make it difficult for payers and providers to identify superusers and evaluate their individual situations.
When health systems in a geographic area don’t share data, they have little chance of noticing a pattern when a single patient visits several facilities in a short amount of time. The total number of annual visits might put a patient in the superuser classification, but without data, it would be up to the patient to recount his or her recent care interventions.
Claims data is often a more reliable source to track superusers.
For instance, when the Camden Coalition of Healthcare Providers took a look at claims data for all three health systems in Camden, a poor city in South Jersey, they found one patient who had more than 100 total visits to various ED and hospitals in the area.
Superusers are a business problem as well as a clinical problem because the disjointed care drives up unnecessary costs for diagnostics and opens the door to medication errors.
“The communication among hospitals needs to improve,” says Catherine Polera, DO, MPH, chief clinical officer in the division of emergency care at Sheridan Healthcare, a consulting firm. “When I was in Newark [N.J.], we tried to connect the emergency departments of different systems, so I could find out what was done for the patient at hospital A, even though we were not connected in any way, except by this agreement to be able to access each other’s records.”
She says every city should share data to decrease overutilization, while allowing greater patient care.
“If I know that the patient just had a CAT scan of the chest, I would not have to repeat that test,” she says. “Just think of how much savings that would be, and it would increase patient safety because that patient would not be exposed to more radiation.”
According to a recent RAND Corporation study, almost 82% of unscheduled hospital admissions come through the emergency department, which is a sharp increase from the previous decade when 64.5% of unscheduled admissions came through the ED.
In another study in the August 2013 issue of Medical Care, a group from Michigan compared hospital admissions over a 10-year period, from 2000 through 2009, using the Nationwide Inpatient Sample. Admissions through the emergency department increased substantially while direct admissions from clinics or doctors' offices declined from 31% to 14% of unscheduled admissions, according to their report.
“The ER was the source of admission for a wide variety of clinical conditions, from medical and surgical disease to mental illness,” says Keith Kocher, MD, MPH, of the department of emergency medicine at the University of Michigan in Ann Arbor, and co-author of the study. “It was also the source of admission for more vulnerable populations like the elderly, minorities and the uninsured.”
He says the two studies demonstrate that the emergency department has become the major portal for unscheduled hospitalizations.
“Administrators and policymakers would be advised to focus their attention on physicians and caregivers in the emergency department who make more of these decisions to admit,” he says. “As acute care management continues to evolve away from primary care providers, this trend also has the potential to exacerbate an already fragmented U.S. healthcare system."
But the information must be examined in context. Some of the patients are very sick, says Dr. Castillo, so the fact that they are superusers doesn’t mean that the care is unnecessary-it’s just that it is possibly the wrong type of care. Patients with chronic conditions would be better served if a primary care practitioner was monitoring their care on an ongoing basis, rather than just handling exacerbations and acute problems piecemeal.
“Some of these patients have serious complaints,” he says. “But they need better primary care or after care to keep them from being repeat visitors.”
Nationally, ED departments handle more than 129 million visits a year, according to 2010 data from the National Center for Health Statistics. Most patients that leave the ED are told to follow up with their primary care provider, but many do not, says Dr. Castillo.
“They key is the continuation of care and actually making sure they have somewhere to go and alerting those who are providing care for them,” he says. “If someone comes into the ED, and you just ‘bandage’ them and send them on their way, that isn’t really going to address their underlying problem. We need community programs that target recidivism.”
Finding these patients and helping them coordinate their primary care is key to lowering excess use of emergency and inpatient care. One strategy that is having some success is making the follow-up appointment before the patient is released from the emergency department.
San Diego physicians implemented an internet-based electronic referral system to improve primary care access for frequent users of ED services. Of 326 patients who were scheduled for an appointment with a primary care physician before their discharge, 81 of the patients actually went to the appointment, which was a 23.8% improvement in follow-up care. However, most patients still failed to act.
In areas where hospital systems don’t communicate with each other, organizations are looking at the emergency medical services (EMS) as the possible point of contact. Using an ambulance to get to the ED increases the cost of the episode, as well as the likelihood that the patient will use multiple facilities.
In 2008, just 933 patients generated 11% of the total EMS transports in San Diego. The ambulance charges for these patients totaled $6.4 million, and most of the money was never collected, which was a community concern. The city initiated the San Diego Resource Access Program (RAP), which identified superusers and assigned a case manager to each.
The program results were presented in a study in the October 2012 issue of Prehospital Emergency Care.
RAP used EMS system surveillance to identify those who frequently called 9-1-1 and had more than 10 EMS transports in a year and assigned them a case manager. The RAP manager enrolled the frequent users in the program, investigated the underlying reasons for excessive use and then coordinated social support beyond medical care. The majority of enrollees were homeless.
Services included helping the patient find not only a primary care provider, but necessary equipment, transportation, mental health and social services and housing. Such hands-on coordination reduced EMS charges during the study period from December 2006 to June 2009. One hospital saw a 28% reduction in ED visits. There was also a decrease in inpatient admissions and length of stay for the RAP patients.
The program, which is ongoing, has become a model for other EMS departments.
“They key is that continuation of care, making sure that patients have somewhere to go and then alerting those who are providing care for them when they come into the system,” says Dr. Castillo, who participated in the RAP study.
The Patient Protection and Affordable Care Act might decrease some overutilization. When more people enroll in insurance plans, providers will have a method for reimbursement other than charity care and bad debt. But health reform is unlikely to change patient habits or the psychosocial factors that contribute to over use, according to Dr. Brenner.
“The Affordable Care Act will give a lot more people coverage, which is great, but it will lead to another really big problem: more people with health care getting disorganized, fragmented and expensive care,” he says.
Dr. Brenner says the real fix on the primary care side is open-access scheduling, which would allow patients to get an appointment more readily and possibly avoid the emergency room.
Dr. Polera agrees that location, ease and availability of office hours are important, as is the doctor-patient relationship.
“When looking at people who frequent the emergency department, it is important to educate them to call their doctor instead of using the system if they have a minor problem,” she says. “If they are calling an ambulance for a minor problem, they are taking an ambulance that could save a life.”
Because the superuser population is so diverse and the healthcare system is so fragmented, patients present a significant challenge to providers who have been tasked with reigning in healthcare costs.
Marie Rosenthal, MS, is a freelance writer based in East Windsor, N.J.