Contrary to popular belief, a recent study has found that most patients who visit the emergency department (ED) four or more times a year have health insurance and a primary care provider (PCP).

Long assumed to be driven by low-income uninsured or underinsured patients, repeat ED super-users have been a significant, and chronic, source of unnecessary healthcare spending in the United States for years. These "frequent flyers," who account for 21% to 28% of all ED visits, routinely visit the ED seeking non-emergency care that would be better provided in the urgent or primary care setting.

In their review of 25 independent studies, Drs. LaCalle and Rabin challenge that "widely held assumptions about the patient population who frequently visits EDs, and their reasons for visiting, have not been, for the most part, supported by research on the topic."

Study Highlights:

• Emergency departments experienced a 36% increase in patient volume from 1996 to 2006.
• "Frequent flyers" (>4 ED visits per year) account for 21% to 28% of all ED visits.
• Uninsured patients represent only 15% of ED "frequent flyers."
• 60% of ED "frequent flyers" carry Medicare or Medicaid coverage.

Drs. LaCalle and Rabin also point out that frequent ED users are more likely to have a primary care physician (95% of pediatric patients have an assigned PCP) and that the primary reasons for choosing the ED was due to the lack of availability of their PCP and the knowledge that the ED was always open.

How do these new findings impact your ED diversion strategy?

If the majority of ED "frequent flyers" have health insurance -- and subsequent access to health plan sponsored resources like 24x7 nurse advice lines, managed care programs, and case management services -- then the de facto decision to visit the ED may have less to do with insufficient access to healthcare resources and more to do with the fact that patients just don't know that other options exist.

Patients have become hardwired to immediately head to the ED when they are experiencing an issue with their health--whether it's a true emergency or not. A relatively cheap and easy way to improve your ER diversion programs is to increase your promotions and build top-of-mind awareness of already available decision support services.  

Another big implication of Drs. LaCalle and Rabin's study is that if the majority of ED "frequent flyers" are insured, then Medicaid, Medicare, and commercial health plans are ideally positioned to have the most impact on reducing the costs created by ED "frequent flyers." 

One way is to use claims analysis to identify patients who have utilized the emergency department 4+ times over the last year. Once identified, RNs can conduct outbound calls to:

1. Coach users on the appropriate use of the emergency deprartment.
2. Promote decision support services like your nurse advice line.
3. Evaluate the need for structured care management and enroll as appropriate.
4. Provide information on alternative healthcare resources.

It's clear there needs to be more research done on who over utilizes the ED and why, but Medicaid, Medicare, and commercial health plans have an opportunity to proactively engage members who are prone to ED overuse and educate them on their healthcare options.