Throughout the country, frequent fliers are impacting hospital EDs in varying degrees. As reported in a series of studies in 2012 for the Annals of Emergency Medicine, frequent fliers at hospital EDs sought emergency care at least four times a year and sometimes as often as 21 or more. Individual patients can account for one or two dozen visits, sometimes more. In 2010, the Department of Emergency Medicine at Mount Sinai School of Medicine in New York reported that frequent users comprised 4.5%–8% of ED patients, but accounted for 21%–25% of all hospital visits. A 2010 Rand Corp. study reported healthcare spending of $4.4 billion on people using the ED for routine, nonurgent care.
"There is a small population driving costs in the system, which given its fragmentation has not been well designed to meet the complexity of their needs," says Allison Hamblin, MSPH, vice president for strategic planning at the Center for Health Care Strategies, a nonprofit health policy resource center based in Hamilton, N.J. "But the pendulum is swinging. We are starting to see more organized care and more integrated programs for these patients with complex needs."
Case manager plan
The frequent flier issue was exemplified at St. Luke's, where a Cedar Rapids woman took the bus—almost as a commuter would, with no sense of urgency—to make 12 visits to the ED in 2011, says Sallie Selfridge, a case manager in the hospital's ED, which logged 55,079 emergency visits that year. Although the patient had congestive heart failure—a chronic condition—there was nothing urgent about the elderly woman's visits.
Hospital executives started to evaluate the process after a social worker and nurse practitioner began comparing notes, saying, "Did you see Fred was back in the ED again today?" Townsend recalls. "The fact they could actually know who these people were on a first-name basis seemed incongruous to the emergency department," he says.
St. Luke's Hospital began a consistent care program to identify frequent fliers who returned to the ED for at least 12 visits in 12 months. The solution is giving these patients assistance in locating alternative care. The effort has been successful in reducing patient trips to the ED. In 2011, 103 patients who were designated frequent fliers made 1,679 visits to the ED. But after involving the patients in coordinated care planning, within a year the same group made only 537 visits.
At St. Luke's, they found that many of the patients use the ED because they don't have a family doctor, and others have difficulty keeping appointments because they lack transportation, have work schedules that make it tough to visit a doctor during office hours, or have financial or insurance issues.
"We wanted to identify these frequent fliers and put together a plan of care for each of these individuals to see if we can find a way to reduce their utilization of the ED—not just to avoid the ED but to get them to more appropriate levels of care, and that's exactly what happened," says Townsend, the CEO.
As hospital officials examined the frequent flier situation, they focused on the financing, and it "came out as a wash," he says. By eliminating the income to the ED with the decrease in frequent fliers, the hospital estimated that it lost about $500,000 in one year related to patients who were diverted to other care.
At the same time, the hospital estimated it saved about half a million dollars by not having to provide additional care and testing for such patients, Townsend adds. "In reality, because of the payer mix of folks coming through the ED, that was roughly a break-even proposition for St. Luke's," he adds. "Yes, we would have generated $500,000 in fees, but we probably were incurring $500,000 in costs; it was a zero-sum game," he adds. "It's the right thing to do for the community and works reasonably well for St. Luke's."
Creating a direct relationship
As Benzer points out, even in Massachusetts, where health insurance is universal, frequent fliers are prevalent at hospital EDs. "Almost all of these patients have been identified as having primary care physicians, and they had insurance, so that wasn't the issue," says Dawn Williamson, RN, MSN, PMHNS-BC, an addiction specialist in the ED at MGH.
Staff physicians and nurses at MGH reviewed their records and formed a team to coordinate various programs for the frequent fliers, or, as they dub them, MVPs or multivisit patients.