The Emergency Department (ED) plays a large role in our country’s safety net health care system. Due to EMTALA, emergency departments are mandated to provide care to anyone who seeks it, regardless of ability to pay. Some feel that the policy invites a lot of abuse, mainly by “frequent fliers”, patients who are often well known to their local ED, kind of like the local drunks at the neighborhood bar.
It might seem like an unfair comparison; however that’s exactly how these patients are often characterized. Though you’re unlikely to see a person denied care for their substance abuse problems or inability to manage their mental illness, there is a stigma against such patients who are believed to be a drain on our country’s healthcare system and a huge driver of already inflated healthcare costs.
Some researchers have addressed the situation head on with a Health Affairs article entitled: “Dispelling an Urban Legend: Frequent Emergency Medicine Users Have Substantial Burden of Disease“. They attempt to further characterize frequent users in NYC emergency departments, and show that some of the judgments care providers and legislators make on “frequent users” (defined as patients with >3 ED visits per year) are unfair and based on misconceptions rather than real data. They show us that the frequent users truly are sick, evidenced by their comparatively higher scores on the Charlson Comorbidity Index (CCI), and contrary to what is often assumed, often fully plugged into the primary care system.
The researchers found that as the number of ED visits per year increased, so did the patients’ level of contact with ambulatory care providers (and in most cases, these ambulatory care visits occurred PRIOR to the patient showing up in the ED). It goes against a common line of thought that ED “frequent fliers” are abusers of the health care system who avoid their primary care doctors due to factors like poor health literacy, issues with access, etc. The frequent level of contact with their primary care providers indicates that these patients were sick, knew they were sick, and were seeking care in the right places, but for whatever reason didn’t get the help they needed and found themselves in the emergency room. In my mind, the relatively high utilization of ambulatory care by the frequent fliers doesn’t indicate that the patients are shut out of the health care system or avoiding it, but that they have been failed by it. I do acknowledge that it is extremely challenging for doctors to provide quality care while working in such a screwed up system, BUT it’s important to maintain some perspective: these so-called “abusers” of the healthcare system are shouldering the larger part of the burden; it is they who experience larger burdens of disease, decreased life expectancy, and poor health outcomes.
It seems we should focus less on what’s happening in the emergency room and more on what’s happening in the doctor’s office in order to understand where and why this breakdown in the system happens. Then we can figure out how to meaningfully address it via policy change.
Are you surprised by any of the data? What surprised you? What didn’t surprise you? Share with me in the comments!
The Minority Health Review 