One of the great hopes for health care reform is that providing insurance coverage to millions of currently uninsured Americans, making it easier for them to get primary and specialist care, will reduce the number of visits to emergency departments, where care is more costly. But a new study by Robert Wood Johnson Foundation (RWJF)/U.S. Department of Veterans Affairs Clinical Scholar Kelly Doran, MD, casts doubt on that premise, suggesting that a significant group of patients will continue to make heavy use of the emergency department even when they have ready access to primary care. The study was published online on April 11, 2013, in the Annals of Emergency Medicine.
Doran and co-authors Maria C. Raven, MD, MPH, and Robert A. Rosenheck, MD, studied fiscal year 2010 data from the Veterans Health Administration (VHA), covering more than 5.5 million patients, all of whom have access to primary care through the VHA system. The researchers found that about 92 percent of the system's patients had one or no visits to a VHA emergency department (ED) over the course of the year. The remaining 8 percent of patients accounted for 75 percent of ED use, including 6.4 percent who visited the ED two to four times; 1.3 percent who visited five to ten times; 0.2 percent who visited 11 to 25 times; and 0.01 percent who registered more than 25 visits during the year.
In all, the researchers found that 87 percent of patients accounted for 30.2 percent of emergency department use. Such “so-called super-users, or frequent users,” they write, “are of concern because their needs seem to be poorly met by standard care systems, their costs are high, and they have drawn the attention of the popular media, which portrays them as a wasteful indication of health system failure.”
Frequent Users Have 'Compromised Life Circumstances'
As an emergency physician, Doran says she can appreciate her colleagues' "frustration" with frequent emergency department users. But she points to "a lot of misunderstandings about frequent ED users, a lot of myths, some perpetuated by the media and by politicians, about them. One common myth is that these patients just aren't that sick, so they don't really need to be in the ED. But what we find in our study is that, in fact, they're the sickest patients; they're among those with the greatest medical problems."
To understand what was at work with frequent ED users, Doran and her colleagues dug more deeply into the data. They found, she says, “a variety of factors associated with frequent emergency department use, including homelessness, heart failure, opiate prescriptions, pain diagnoses, and schizophrenia. So, for example, homelessness increased one's odds of being in the most frequent use group more than six-fold. Just 1.7 percent of VHA patients who didn't use the VHA’s emergency department during the year were homeless, but 45 percent who had 25-plus visits were homeless.”
In short, she says, “Just as we see in the civilian population, frequent users of the ED in the VHA generally have severely compromised life circumstances and high levels of psychosocial dysfunction in addition to medical needs.”
Whether some significant share of these patients' visits to the emergency room could have been avoided is an unresolved question, Doran says. “Frequent emergency department users aren't always non-urgent users,” she explains. “Often they're people presenting with a bad exacerbation of some disease or heart condition, or some other serious problem that requires emergency department care.”
She cautions that it’s difficult to draw conclusions about whether a patient’s decision to visit the emergency room is warranted from an examination of data on the eventual diagnosis—a common yardstick. “A patient may come to the emergency room for back pain," she explains. "In a database, that might look like something a patient should see their primary care provider about. But, while back pain is most often due to a simple muscle spasm, the problem could also be a symptom of something very serious. So it’s hard in retrospect to say they should have waited and gone to their primary care provider instead.”
Implications for Health Care Reform
In an editorial published in the same edition of the Annals of Emergency Medicine, Jesse Pines, MD, MBA, director of the Center for Health Care Quality, and an associate professor in the Departments of Emergency Medicine and Health Policy at The George Washington University, observes that the VHA is similar in important ways to an accountable care organization, a care-delivery model that is a "cornerstone" of health care reform. For that reason, ED use patterns by VHA patients could offer important insights into how health care reform might—or might not—affect emergency department use more broadly. Pines writes:
[P]olicy-makers should recognize that because a not insignificant number—8 percent—of VHA beneficiaries are frequent ED users in a system resembling an accountable care organization, EDs provide important, nonsubstitutable services for the most vulnerable. These services are in high demand despite ready patient access to alternatives and providers’ access to complete records. EDs offer continuous care and provide quick access to advanced services such as highly trained physicians, radiography, medications, specialty consultation, and social work services in ways that are not replicated in any other outpatient system in the VHA. EDs are there when patients need them, particularly the most vulnerable and chronically ill, and those with chronic pain.
Noting that several of the factors that seem to drive ED use involve compromised life circumstances of one sort or another, Doran and her colleagues observe that the effort to reduce ED use by its most frequent patients should look not just at health care structures and payment models, but to social services. "[T]he strong association between psychosocial needs and ED use suggests that interventions aimed at reducing ED use will not be successful unless they address these needs in addition to medical problems," they write. "On a societal level, our findings support recent research suggesting that improved health outcomes may be realized through increasing expenditures for social services such as housing subsidies and income supplements."