Health Policy Journal Club, Health Policy, Advocacy

Health Policy Journal Club: The Best Medicine Isn't Medicine At All

Frequent ED utilizers have various interdisciplinary needs clinicians may not identify.

With the increase in Emergency Department (ED) visits in the past decade comes an increase in wait times, spending, and overall burden on the emergency care system. This has led policy makers to focus on increasing efficiency, with one area of focus being “frequent and superfrequent ED users” (defined in this study as 4-17 and 18+ ED visits in one year, respectively) who constitute a disproportionate share of ED visits and cost.

While there is ample literature on frequent ED users, there is still no consensus on the best interventions to reduce usage in this population. The authors of this study believe that this is likely due to a lack of data integration across medical and nonmedical care services, leading to unclear information on the true cross-sector effects of interventions directed towards reducing ED usage.

This study sought to retrospectively examine the usage of medical, behavioral health, and social services of ED users in the San Francisco Health Plan, the county’s primary Medicaid managed care plan. The authors utilized the San Francisco Department of Public Health’s Coordinated Care Management System (CCMS), a data repository that links the source data from multiple entities across the county, creating an integrated record for any individual patient who utilizes many of the county’s medical, behavioral, or social services. They extracted data from CCMS and linked them with data on beneficiaries of the San Francisco Health Plan, allowing them to identify nonfrequent, frequent, and superfrequent users of EDs within and outside of the county-funded care system.

The results of this study showed that frequent and superfrequent users on average had more comorbidities and utilized more outpatient primary, specialty, and mental health care than their nonfrequent counterparts. They also had disproportionately more markers of social need including experiencing homelessness and interacting with jail health services.

It is clear from this study that frequent ED users are a population with many interdisciplinary needs, and integrated data systems can help identify needs that might be otherwise obscured when focusing on a single, siloed department. Systems CCMS could also allow for better evaluation of interventions designed to improve the health of frequent users and reduce the financial and operational burdens on a region’s EDs.

Abstract: Kanzaria HK, Niedzwiecki M, Cawley CL, et al. Frequent Emergency Department Users: Focusing Solely on Medical Utilization Misses the Whole Person. Health Affairs. 2019;38(11):1866-1875.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.

PMID: 31682499

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.