Practice Management: 30-day Readmissions and Frequent ER Users

The problem of frequent emergency department users has been an ongoing discussion within the medical community for years; this has been an escalating problem in the health care system. As more studies indicate the need to redirect these patients into ‘more appropriate channels of care,’ the impact on private medical practices and how they will participate in this proposed coordinated care has yet to be determined.

According to an article published by HealthLeadersMedia.com, the American College of Emergency Physicians released several studies this week that analyzed data about patients who visit EDs frequently. Robert O'Connor, MD, FACEP, and ACEP board member as well as Chair of Emergency Medicine at the University Of Virginia School Of Medicine in Charlottesville, stated each study focuses on a different aspect of frequent ED visits.

A report published by Simone E. Miller, Robert E. O’Connor, MD, MPH, and Chris A. Ghaemmaghami, MD, from the University of Virginia Health System, Department of Emergency Medicine, found that frequent ED users made up 20% of all patients and these patients accounted for nearly 40% of the visits.
These studies indicate that high repeat users, once admitted to the hospital, are more likely to require readmission.  This news is worrisome to ACEP President, Andrew Sama, MD, because of the recently enacted rule than penalizes hospitals for 30-day readmissions. Sama stated,

We need to focus on implementing plans to attempt to manage these patients better. What does that mean? Physicians, family members, social workers, and home care personnel have to work together and attempt to try to manage [patients] better and prevent them from being hospitalized.

The Phoenix Physicians hold a monthly conference call to address the challenges facing hospital administrators and staff including medical billing and coding. Dr. Rob Scott, CEO of the Phoenix Physicians, moderates the discussion among panelists who are experts in their field. On September 17, 2012, the topic was Frequent ED Users: Latest Approaches to Management.

During this discussion, Dr. Malcolm Doupe, PhD, University of Manitoba, said,

When they’re not using the ER as a surrogate for other healthcare services they also have many contacts with their primary healthcare system, not the same doctor but many, many different doctors.  There is definitely a trend amongst these individuals in terms of their healthcare use pattern; mental health is a huge issue for these people.  If you look at the general characteristics of them, you can start to get an idea that if we were trying to help these individuals, what type of strategies could come in place to do so.

In concurrence, Dr. Ellen Weber, MD, University of California, San Francisco, stated,

Sometimes it’s because they have no place to follow up or they are unreliable in terms of follow up or they have no housing, and therefore we don’t know how we’re going to get back in touch with them.  But for the most part, if I were an Administrator, I would not just focus on the frequent ED use, I would focus on the frequent ED user who’s getting admitted and work from there.  This is probably a chunk that is likely sicker and where a certain intervention such as chronic illness care would probably be more effective.

Dr. Maria Raven, MD, University of California, San Francisco, added this opinion to the discussion:

They’re generally a fairly sick group and the more visits you have, the more you see these certain characteristics.  I think that bares out until you get to these folks that are really, really heavy users, kind of this super user group as some people are saying recently; and there you get more into very high levels of substance use and mental illness and I think a lot of housing issues as well when you isolate that group.

In a separate study conducted by the Medicare Payment Advisory Commission of the Medicare population, MEDPAC identified that 60% of emergence department visits were preventable, as well as 25% of hospital admissions.

Rutgers University's Center for State Health Policy was given a $14.3 million dollar grant by the Centers of Medicare & Medicaid Services this year to address this issue of repeat, frequent ED users. Over the next three years, the Center will work in coordination with hospitals in Pennsylvania, Colorado, California, and Missouri. The goal is to coordinate care for "hot spotters" – patients who visit emergency departments four times within a year. The team-based approach also involves nurses, social workers, and community health workers. Rutgers predicts this model could potentially save $67.7 million by diverting 2,500 high frequency ED users to more appropriate channels of care.

All these studies state the need for better coordination of care. The panel of experts from the Phoenix Physicians education series clearly identified that many of these frequent ED patients are chronically ill. Many suffer from mental illness and substance abuse. They also appear to lack proper housing. These people are part of the ‘at-risk’ population, considered to be on the fringe of society. It is ironic that these ‘forgotten’ people are now making themselves known by the pattern of frequent ED use, hospital admission, and hospital readmission. This issue affects more than just the health community; it requires the attention of society at large. The need to provide compassionate, coordinated care for these at-risk patients will address the financial solvency of the health care system. It may also improve the quality of life for these patients by providing more proactive preventative care.

Dr. Malcolm Doupe, PhD, University of Manitoba, made this profound statement:

With the technology that exists in our healthcare system today in terms of profiling users and patients, as a general rule of thumb you can’t manage what you can’t measure.  It’s dangerous to try and fix the entire thing at once because it is very multifaceted.  Take a group of people that you want to help, understand who they are and based on those characteristics, put something in place to try and help them.  But baby steps, not trying to do everything all at once.

Clinic Service is a team-based business that exists to maximize the financial return for a community of medical providers through medical billing, EMR implementation, and physician practice management consulting. We strive to be advocates for private practice physicians. Please contact us to learn more about our services. Additionally, we welcome comments on our blogs. As a private practice physician, do you believe the issue of frequent ED users could impact private medical practices in the future?

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