Ch. 2 - Serving the Forgotten: The EM Safety Net
Jasmeen Kaur, DO
The emergency department is the one place in the U.S. health care system where care is guaranteed, and for some patients, emergency care is the only medical treatment they receive. People using substances, those experiencing mental health crises, those with nowhere else to go come to the ED.
Individuals who visit the ED frequently can tax health care resources. Afflicted by limited or poorly coordinated primary care, chronic and psychiatric diseases, and a variety of socioeconomic factors, these high utilizers face an uphill battle in managing their health.
The emergency department is a critical safety net in American society – and frequent use of the ED is a critical benchmark for policymakers, payers, and the emergency medicine team.
Why It Matters to EM and ME
Regardless of the name used for frequent users or high utilizers, the individuals who visit the ED frequently can account for a disproportionate share of ED visits and resource utilization.
Frequent use of the emergency department is a critical benchmark for policymakers, payers, and the emergency medicine team, as it indicates unmet social needs for patients with complex needs. These users may lack resources in the context of housing, social support, end-of-life planning, food security, or mental health care compared to non-frequent users. The emergency department is a critical safety net for these individuals, which positions us at a critical point to affect morbidity and mortality in these patients while advocating to improve their overall health condition.1
How We Got to This Point
Questions about the appropriate use of EDs in the health care system and potential overuse have been debated for many years. Prior work shows that a majority of visits to the ED do not end in admission to the hospital.1 Individuals come to the ED for many reasons, even seeking primary care because of convenience, accessibility, or problematic or non-existent insurance coverage. In the United States, the EMTALA law requires that EDs stabilize all patients, regardless of their ability to pay.
There are a number of potential reasons for concern regarding the overuse of EDs. Care provided in the ED can cost more compared to other sources of care. Overcrowding from a multitude of causes, including high utilizers, carries a number of adverse consequences, including longer wait times and worse health outcomes with higher mortality for all patients. When patients regularly use EDs for ongoing health needs, they do not receive the same continuity of care or preventative care they would from a primary care physician, which could affect the overall quality of care they receive and their health outcomes. One of the challenges in addressing potentially inappropriate utilization of EDs is that it is quite difficult for patients to determine what is inappropriate versus what’s a true emergency.2 Let us take a look at defining terms used to describe individuals who utilize the ED frequently.
Defining High Utilizers
Patients with frequent ED visits are often portrayed as uninsured, unnecessarily clogging EDs by presenting with primary care complaints that do not need emergent service. But these widely held assumptions about the patient population who frequently visit EDs and their reasons for visiting have not been supported, for the most part, by research on the topic. Instead, the drivers of frequent utilization can be a lack of insurance, scheduling challenges while working, timely access to limited services such as mental health, more chronic medical conditions, and much more.
The definition of a high utilizer varies, but when defined as 4 or more ED visits per year, frequent users accounted for 4.5% to 8% of all ED patients. These patients contribute 21% to 28% of all ED visits.3 Let us delve into the demographics and acuity these patients present with further. Among sex and racial groups, women and Black persons are disproportionately associated with frequent ED use. However, national data shows that in absolute numbers, the majority of frequent ED users are white (60%).2 A bimodal distribution is observed, with increased risk in patients aged 25-44 years and those older than 65 years.
Insurance status has been central to discourse on ED crowding and ED “overuse.” Many studies on frequent ED use have considered the influence of insurance status and have found this patient population to be predominantly covered. The uninsured represent only 15% of frequent users and are no more likely to be frequent users than they are to be occasional ED users (<4 visits/year). Among all uninsured adults, only 2% use an ED 4 or more times per year. What has emerged from the data, however, is that a high proportion of Medicare and Medicaid patients frequently seek ED care.4,5 Among those patients who can be characterized as “occasional” users, 36% are publicly insured versus the 60% of frequent users who carry Medicare or Medicaid.
Frequent ED users also tend to be sicker than occasional users. The probability of hospital admission is greater for frequent users versus occasional ED users. Frequent users have a preponderance of exacerbations of chronic illness such as renal failure, COPD, asthma, sickle cell disease. Patients younger than 65 years and receiving Medicare are associated with significantly higher rates of mental health diagnoses than any other group, whereas Medicare patients older than 65 years more commonly presented with cardiovascular, gastrointestinal, and urinary tract complaints.
Frequent users heavily rely on other parts of the health care system as well. They are more likely than occasional ED users to have made primary care visits in the previous year. These findings underscore the observation that most frequent users indeed do have primary care physicians. Compared with occasional ED users, these patients are more likely to be treated in a hospital clinic or have a change in source for their usual care; 19% reported unmet medical needs, another independent risk factor for ED visits. The finding that frequent ED visitors are about 6 times more likely to have been hospitalized in the preceding 3 months (odds ratio 6.1; 95% CI 4.1 to 8.9) reinforces their claims of unmet need.4
Categorizing Frequent Users
To better understand this population, the Congressional Research Service outlined several categories of high utilizers based on their usage patterns which may lead to potential solutions.6
- Frequent non-emergent users: This group includes individuals with private insurance and a primary care physician. These individuals may have barriers to accessing primary care resources leading them to seek care for non-emergent conditions. This group typically has fewer chronic illnesses.
- High-cost health system users: These patients generally have 4-9 ED visits per year and have a high burden of chronic disease and are more likely to be severely disabled. They may have underlying mental illnesses or substance abuse. This group is the most expensive for health care system, as they are more likely to require extensive testing.
- Very frequent ED users: This group is a small portion (1.7%) of patients with more than 10 ED visits per year. This group is more likely to be male and suffer complex medico-social factors, including higher rates of disability, mental illnesses, substance abuse, and homelessness. They are less likely to require hospital admission and are less expensive for the health care system.
As evidenced by these different categories and diverse drivers of emergency department utilization, this is a diverse group with an array of medical and social needs that must be addressed to affect the overall trajectory of ED utilization in the country.
Current State of the Issue
In 2020, two significant events occurred to impact ED utilization: a global pandemic and the passage of the No Surprises Act as part of a COVID-19 relief package.7 The effects of both are still playing out in every sector of the house of medicine – starting with emergency medicine.
The pandemic radically disrupted ED utilization: In the first year of the outbreak, weekly ED visits dropped by at least a third.8,9 The sharpest declines were seen among patients with chronic conditions, but some studies also showed that super-utilizers continued to seek care in the ED for non-emergent conditions.10 Emergency medicine absorbed the brunt of the COVID-19 crisis, yet the precipitous decline in patient volumes led to a cutback in staffing, even as burnout drove health care workers from the specialty.11 Meanwhile, patients who delayed care for chronic conditions during the pandemic began experiencing acute problems, leading to a surge in emergency visits - stressing an already stressed system.12
Now three years removed from the start of the pandemic, emergency department volumes are recovering across the country with predictions showing that they are likely back already to pre-pandemic levels.13 While federal data will lag behind for one to two years, most emergency physicians today are experiencing busier and more crowded care environments than before the pandemic as the challenges of staffing, increased health care demands due to delayed care, and more weighs on the emergency department care team. The question of whether the high utilizers will return at their prior levels remains to be seen in the data.
History has shown us that when resources are stretched thin and financial pressures begin to mount, the plight of the chronically ill social determinants challenged high utilizer of the emergency department can become a target for "quick" savings. As seen in the Great Recession when states like Washington sought to limit emergency department visits for those with high utilization, but emergency conditions, the need for emergency physicians to speak up is great.14 It is likely that additional efforts to cost shift, eliminate coverage, and reduce perceived unnecessary emergency department care will be proffered in the future, often without addressing the underlying drivers of that utilization. Emergency physicians will need to continue to advocate for addressing the social determinants of health and holistically caring for the chronically ill patients rather than simply denial of care.
- The emergency department is a critical safety net for patients with complex needs (such as social admits, frequent utilizers, "unnecessary" ED visitors, patients with opioid use disorder and mental health crises, unhoused patients) and can provide critical interventions to improve morbidity and mortality in these patients.
- The construct of "unnecessary emergency visits" fails to recognize the systemic issues leading patients to come to the ED and the critical role of the ED as a safety net.
- Frequent utilizers can be scapegoated by policymakers as drivers of cost that can be easily eliminated with addressing the underlying barriers to care.
- Raven MC, Kanzaria HK. Frequent Emergency Department Use: A Social Emergency Medicine Perspective. In: Alter HJ, Dalawari P, Doran KM, Raven MC, eds. Social Emergency Medicine Principles and Practice. Springer Nature Switzerland:2021:143-155.
- ASPE Office of Health Policy. Trends in the Utilization of Emergency Department Services, 2009-2018. U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. March 2, 2021.
- Pham JC, Bayram JD, Moss DK. Characteristics of Frequent Users of Three Hospital Emergency Departments. Agency for Healthcare Research and Quality. Access at: https://www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html#ref2. Last Revised July 2017.
- LaCalle E, Rabin E. Frequent users of emergency departments: The myths, the data, and the policy implications. Ann Emerg Med. 2010;56(1):42-48.
- Sommers AS, Boukus ER, Carrier E. Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms. Res Brief. 2012;(23):1-10, 1-3.
- Mann C. Targeting Medicaid Super-Utilizers to Decrease Costs and Improve Quality. CMS. July 2013.
- U.S. Department of Labor. No Surprises Act. Accessed December 2022.
- Nourazari S, Davis SR, Granovsky R, et al. Decreased hospital admissions through the emergency department during COVID-19 pandemic. Am J Emerg Med. 2021;42:203-210.
- Yu J, Hammond G, Waken RJ, Fox D, Joynt Maddox KE. Changes in Non-COVID-19 Emergency Department Visits by Acuity and Insurance Status During the COVID-19 Pandemic. Health Aff (Millwood). 2021; 40(9):1465-1472.
- Alwood S, Musso MW, Jones GN, et al. The impact of the COVID-19 pandemic and governor mandated stay at home order on emergency department super utilizers. Am J Emerg Med. 2021;48:114-119.
- U.S. ASPE Office of Health Policy. Issue Brief: The impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce. May 2022.
- Kelen G, Wolfe R, D’Onofrio G, et al. Emergency department crowding: The canary in the health care system. NEJM Catalyst. Sept. 28, 2021.
- Vizient. Pandemic reocvery timing and helath care projections for the next decade. Published 2021, accessed at: https://www.vizientinc.com/-/media/documents/sitecorepublishingdocuments/public/vizientadbeckerscovidrecoverytimeline.pdf?position=t3_impact.
- Gallegos A. Judge Halts Washington State Medicaid limits on ED visits. AMA News. December 5, 2011. Available at: https://amednews.com/article/20111205/government/312059956/4/.