Emergency Department “Frequent Fliers”

John V. Jacobi

Emergency Department “Frequent Fliers”: Addressing Patient Care and Hospital Solvency With Community Collaboratives

            Recent work with community providers and public health officials has exposed me to a growing literature on a serious health delivery and finance issue: the dysfunctional treatment of the small number of very high utilizers of hospital emergency departments.  The bad news is that these patients’ fundamental problems often go unaddressed, notwithstanding substantial hospital spending that often go unreimbursed.  The good news is that several recent projects have developed promising cooperative mechanisms that can dramatically improve health outcomes while freeing ED resources for other purposes.  These projects step in where, unfortunately, health reform efforts fear to tread. 

Hospitals are health anchors of medically underserved communities.  Alternative sources of care can be scarce; by mission, and often by licensure requirement, hospitals and their EDs step into the breach to serve as comprehensive care providers.  Fiscal strains and evolving practice patterns challenge hospitals’ continuing ability to backstop medical and social care in their communities.  A persistent aspect of this challenge is the phenomenon of extremely frequent ED users.  These patients may have multiple health concerns including mental illness, chronic physical conditions, and substance abuse, as well as serious social problems including homelessness, domestic violence, and extreme poverty.  Standard episodic “catch and release” treatment saps hospital resources and disserves these very vulnerable patients. 

            Hospitals have every reason to focus on this issue.  The dearth of primary care physicians, particularly outside regular office hours, crowd urban EDs with non-emergent cases.  The most frequent users raise concerns different in type and greater in magnitude, and divert hospital resources from true – or other – emergencies.  For hospitals committed to their community mission, this is not an EMTALA problem.  Rather, they are concerned for very needy patients and are increasingly aware that medical care alone tends to simply kick the can down the road.   Further, the high unreimbursed costs of these frequent users can burden urban hospitals with unfavorable payer mixes.

            Interesting work on these concerns in being done for the benefit of both patient and hospital.  For example, the Camden Coalition of Healthcare Providers, comprising physicians, social workers, and hospital administrators in Camden, New Jersey, is tackling the needs of the most frequent utilizers.  It examined the ED use of 43 frequent utilzers from 2002 to 2007.  In this six-year period, these 43 patients racked up 1,663 ED visits, generating over $26 million in charges, most of which were not collected, as many of the patients were uninsured.  The single highest ED utilizer generated almost $5 million in charges during that period.  In response to a needs assessment, the Camden project has assembled a cadre of professionals and gained the cooperation of the city’s EDs to secure services that can resolve the patients’ underlying problems.   

            Eight California counties participated in the planning and/or implementation stages of a six-year frequent users project funded by the California Endowment and the California HealthCare Foundation, and supported by the Corporation for Supportive Housing.  A 2008 Final Evaluation Report by Dr. Karen W. Linkins and colleagues from The Lewin Group contains a wealth of information on the nature of the frequent user problem and its possible solutions.  The report, available on the Corporation for Supportive Housing’s web site, confirms that the patients’ fundamental problems are largely non-medical, calls for broad a range of advocacy and social service interventions, and assumes the continuing central role of hospitals.     

            Researchers at the Camden and California sites report physical, psychosocial, and social presenting conditions for frequent ED users.  In Camden, 73% presented with housing problems, 58% with substance abuse problems, and 30% with mental illness.  The California project, with a larger pool of participants, reported 45% homeless, 53% with substance abuse problems, 32% with mental illness, and 65% with serious chronic illnesses.  Over two-thirds of the California participants presented with at least two of these four conditions.  These findings are consistent with studies of high-cost hospital patients generally.  An April 2009 report from United Hospital Fund’s Medicaid Institute reported on Medicaid beneficiaries with histories of high-cost hospital use.  Two-thirds to three-fourths of those patients had chronic conditions – most of them more than one.  Their usual source of care was the ED, and many had housing problems and a lack of family supports. 

            These projects are reaching well beyond hospital walls to resolve the needs of very vulnerable patients.  Committed to breaking out of a medical model of resolving the complex presenting conditions, the hospitals have found willing (if underfunded) partners capable of providing needed services.  A list of the promising mechanisms suggested by these efforts should include the following. 

1.      Individual case management.  These are expensive patients.  The scale of their resource consumption justifies devotion of substantial professional resources to the management of their medical and social problems.  The Camden project uses nurse case managers, social work case managers, and community health workers.  The Camden and California projects employ case management to address health concerns and to maintain solid referral relationships to housing, substance abuse, and community mental health services.  This case management function can be hospital-specific.  Often, however, hospitals in one community share frequent users.  Under these circumstances, hospitals can collaborate to create a professionally staffed intensive case management and referral program.  These joint ventures could address a “central goal” of the California project, which is to “invest in and stimulate the development of a comprehensive, coordinated system of care to address the needs of frequent users.” 

2.      Medical-legal partnerships.  Barry Zuckerman, a pediatrician at Boston Medical Center, had an inspiration about 20 years ago.  He realized that many of the medical problems experienced by the children he served in the hospital’s pediatric clinic were exacerbated, or caused, by distinctly non-medical problems, for example, substandard housing, lack of access to a sound diet, and unsettled family circumstances.  That insight led to the creation of a medical-legal partnership which strove, as is described in the National Center for Medical Legal Partnership’s web site, to “improve the health and well-being of individuals, children and families by integrating legal assistance into the medical setting.”  Under this model, hospitals (and now health clinics) host legal services offices that can address legal and social problems frustrating the resolution of serious health concerns.  If poor housing is exacerbating asthma, or the lack of income supports deprives a chronically ill child of a suitable diet, housing and public benefits representation can directly improve the patient/client’s health status.  The partnerships are now located in about 160 hospitals and health centers nationally.  The benefit to frequent ED users of such services is obvious.  The National Center’s web site provides detailed assistance on the creation of such partnerships.

3.      Medicaid waivers.  Many frequent users of ED services are uninsured, but are eligible for Medicaid.  Some are enrolled in Medicaid, but need basic services Medicaid does not reimburse.  Hospitals, for example, cannot bill Medicaid for the costs of obtaining housing for a homeless patient, or SSI coverage for a patient with a disability.  Obtaining those results is, of course, good for the patient’s health.  Those results may, in addition, greatly reduce the patient’s medical costs, as fewer ED visits and admissions would be needed.  Section 1115 Medicaid waivers permit creative funding of just such efforts.  One requirement of Medicaid waivers is the promise that expansion of reimbursement to new services not increase the overall cost of the Medicaid program to the federal government.  The pilots show the promise of “cost neutrality,” as the cost of expanded social services and case management can be offset by the reduction in medical costs for these expensive patients.  Waivers could add federal Medicaid matching payments to the pool of money available for a range of necessary but normally unreimbursed services, thereby enhancing the prospects for sustaining the programs. 

Will these interventions work?  For patients, the answer appears to be “yes.”  The Camden program, still in its early stages, has reported remarkable success in arranging long-term and transitional housing, and enrollment in public assistance programs.  The California programs connected over one-third of their homeless patients to permanent housing or HUD vouchers, and most of the balance to shelters or longer-term transitional housing.  Of the patients presenting with mental health concerns, the California projects connected 42% to community mental health services.  Of those presenting with substance abuse concerns, 20% were connected to drug treatment. 

            Do they save hospitals and payers (including Medicaid) money?  The preliminary evidence seems positive as well.  The number of ED visits per year for the California frequent users dropped 35% after one year of services, and 61% after two years.  The mean and total ED charges dropped 59% after two years – the total from $2,744,612 to $1,132,118, and the mean per patient from $11,388 to $4,697.  Is there a causal link?  The Lewin Group’s analysis suggests that there is, and that the investment in a variety of services for frequent users resulted in both improvements in the health of the patients and reductions in the cost of providing health care services.  

            Success will require investment.  The community partners providing housing, mental health, and substance abuse services must have resources, and hospitals will take on new burdens as well.  Expanding the vision of “health” care along the lines described in these projects may in the end be socially cost neutral, but will require start-up costs, and flexibility in governmental funding streams.  Through Medicaid waivers and direct government support, funding and services can be redirected and reorganized for human and fiscal benefit.


Author bio:  John V. Jacobi is the Dorothea Dix Professor of Health Law & Policy at Seton Hall School of Law in Newark, New Jersey.  john.jacobi@shu.edu.

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