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Two Ways to Deal with ED "Frequent Flyers"

Two Ways to Deal with ED "Frequent Flyers"
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Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel.

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"He returned a third time that night. When he became aware of the man's presence again, a doctor entered his cubicle and punched him in the abdomen. The patient was not injured."
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A hospital in Maryland has come up with a novel solution for patients who are “frequent flyers,” politically correctly termed “super utilizers,” in its emergency room.

After identifying 318 people who visited the emergency department four or more times in 4 months, Sinai Hospital referred them to primary care doctors, social services, mental health and substance abuse programs, and insurance providers.

One young man who made eight trips to the emergency department in 4 months, often by ambulance, was assigned to a care coordinator who worked with him to arrange his medical care and deal with his nutritional, social, and economic problems.

The project, detailed in a recent Baltimore Sun article, cost the state $800,000 over 3 years. But it has resulted in 1000 fewer emergency department visits and paid for itself. In fact, the patient described above has not felt the need to visit the emergency department once since he enrolled in the program.

A few other hospitals in Maryland have seen similar results, although each hospital has unique issues. Some have discovered that the patients have a more pressing need for social interventions than medical care.

Because they save money in the long run and the patients are healthier, the hospitals are not losing revenue with fewer emergency visits.

A doctor in Japan took a more direct approach.

According to Asian media outlet Rocket News, a man with elbow pain was seen in the emergency department of Mutsu City General Hospital. He was treated and released, but showed up a few hours later with abdominal pain. He was again examined and discharged.

He returned a third time that night. When he became aware of the man’s presence again, a doctor entered his cubicle and punched him in the abdomen. The patient was not injured.

An investigation found the patient had been seen in the hospital’s emergency department 18 times in the first 8 months of 2015. On many occasions, “he was noticeably intoxicated and belligerent with staff.”

Most of the comments on the Japanese website originally reporting the incident were supportive of the doctor. They ranged from “That doctor is innocent. They should have arrested the patient” to “It would have been better if they just went ahead and euthanized the patient.”

The doctor apologized to the patient, and the hospital punished the doctor by giving him “a strict talking-to.”

I suspect the consequences for the doctor would have been a bit different had this occurred in here in the United States.

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel.

30 Comments

  1. If you think that spending $800,000.00 on patients saved 1,000 E.R. visits,I would like to know who came up with these numbers,and how.Poor Baltimore.Safest Liberal city in the States.And the Sun sanctions spending more on social workers too,of course.And,by the way,rest assured,about your patient mentioned earlier.He’ll be back again !!!!

    Reply
    • I disagree, the cost is far far too high, but it involves a hospital soyou are paying salary taxes retirement health insurance AND facility fees so 300K a year is possibly a bargain- of course the marginal costs of seeing extra patients are near zero so the only real savings are in patient satisfaction

      Reply
  2. Punching patients It is a negative step & does not solve anything. That doctor should have more serious consequences than “a talk”.

    Patients with chronic conditions/pain, should have an actual PCP, who would help connect them to the support team (social services, home visits, mental & physical re-hab) and have a plan on how to deal with possible urgent matters, to prevent the run to the ER.
    If the client know that they will be seen at the PCP’s office soon enough, they would feel re-assured. But that is one of the system flaws, lack of continuity and lack of access.

    Reply
    • The doctor’s punishment was not just a talk; it was a “strict” talk.
      ***
      Yes, lack of continuity and access are problems. Bu where I live it is impossible to see a PCP on short notice. Patients are often told to go to the ED even during normal business hours.

      Reply
  3. (Sigh). We we should just bring back “debtors prison.” Where 8 hours of physical work a day (6 days a week) yields an honest $1/hr toward retiring your bill.

    Reply
    • I hope you are not serious.

      Reply
      • Don’t think so, think he was making a comment about some others’ attitudes here.

        Reply
        • Yes. On further review, I agree.

          Reply
  4. As someone who’s entire body has been effected by the Essure device I’ve seen more of a hospital than I would ever like. It’s hard not to go to the ER when ur entire left side of ur body goes numb or when u have chest pains with nausea and hot flashes. I’m at a high risk for blood clots so I know at anytime I could have a stroke. I know ER Drs get tired of “frequent flyers” but I hope they also realize some of the patients that are given that label really don’t want to be in the ER and are only there bc they would rather be safe than sorry. At 33 yrs old I can say I absolutely hate the ER but I have 3 kids that can’t afford for me to blow off symptoms that all Drs tell u not to ignore. I wish there was another way besides going to the ER to know if I’ve got something serious going on but there isn’t. What’s really a pain is when after 3 yrs and 7 different specialist no Dr can explain why it keeps happening. What I hate the most is being on Medicaid bc I know what it’s costing and I hate being labeled or feeling like a burden to other taxpayers. So the next time u as Drs get a “frequent flyer” please just take a minute bc that patient might not want to see u anymore than u do them.

    Reply
    • Thanks you for adding your perspective into the conversation. I am sorry that you have these problems. I agree that some people have no choice but to use the ED. The system is broken. No doubt about it.

      Reply
    • Yes, but is 27 hours a day enough? Why not go around the clock–33 hours a day?

      Reply
  5. Sounds good, BUT no way my homeless, drunk, narcos, hypochondriacal patients are gonna do anything other than: “I want what I want when I want it” !! Also, they are not exactly computer savvy, nor responsive to reccomendations froma tablet!

    Reply
    • My patients were not computer savvy either. I love all those people who think everyone is like them. That goes for teaching patients to be compliant too.

      Reply
  6. US Expression – The squeaky wheel gets the grease.
    Japan Expression – The nail sticking up highest gets hit.

    Here is an ED care coordination system that reduces ED over-utilizers and has a remarkable ROI — http://smart-er.net/smartcontrol.

    Reply
    • This must be some company. According to the link you sent, “Clients have access to 27/7 technical support.” I think the days are 27 hours long on Jupiter or somewhere.

      Reply
  7. “Frequent flyers” have no skin in the game. If an innovative could be devised to forcibly take payment from whatever their income stream is, this would immediately disappear. An amount as low as $10 per visit would dry up as much as 90% of the problem. People HATE losing money, no matter how little, against their will. To prove it, a pilot program should be started. Ideas anyone on how to do this?

    Reply
    • I have no idea how this could be done. The idea of charging frequent flyers a nominal fee is not new. I can recall suggesting it when I was a resident in the early 1970s. At that time, I was told that it was illegal to charge Medicaid recipients even $1.00 as a deterrent-type of co-pay for a visit. I suspect that is still true today. It’s also illegal to refuse to see anyone who presents to your emergency department.All comers must be evaluated.

      Reply
    • A portion of all insurance, Medicare, Medicaid and commercial, goes toward a HSA from which a small percentage (1-2%) of all medical expenses is extracted. It is not cash, which levels the playing field and circumvents the laws seeking to ensure access. The HSA becomes an annuity at 65, transferable to your children ( might make for better end of life are decisions). The more you see the doctor, unless police report says it was not your fault, the more you lose. You can draw cash from this account with tax penalties, as you would an IRA or 529, such that it has relevancy to the myopic. This is the only kind of policy that will ever truly reduce health care expenditures, period.

      Reply
      • Interesting idea. It might work for a lot of people. ED frequent flyers often don’t have any insurance at all, not even Medicaid. They aren’t thinking of their retirement or their kids.

        Reply
    • Can’t force even a one dollar payment at the door thanks to EMTALA. Charge them the pack of cigarettes in their pocket, perhaps?

      Reply
    • There is a federal law that no one can be refused evaluation in an ED

      Reply
    • That will have to come from the social welfare. If the government made it a requirement for anyone with medical to pay a copay like any other private insurance, then this kind of frequent fliers should dratically reduced.

      Reply
    • Here’s a prime example why they need to pay at least a copay: My cousin, who never worked a day in her life, spent her teenage and adult years using everything including heroin, arrested for prostitution and almost charted with aiding in a bank robbery has SSI and Medi-Cal and spends 4-5 days EVERY WEEK at one hospital emergency room or another because although she professes to be “clean for 5 years now”, her current addiction is prescription medication and hypochondia. “I have a blood clot…I have congestive heart failure…I have cancer…I have liver failure” This was all within the last 2 weeks and she has been going through 3 different ER’s, a therapist, a Primary doctor and a fortune in tests. She DID quit telling me yesterday because I told her that she would be in the hospital or dead at this point if she was that sick. On the other hand, I have worked full time since I was 16, still in high school, graduating a full year early with a 3.8 GPA. We had similar upbringings, my childhood was no picnic either and nothing was handed to me nor did I ask for it. Now in my 40’s I suffered a severe back injury, cannot work, and am waiiting for SSDI benefits. I have to still pay for my insurance and cannot get healthcare benefits until I am eclared “permanently disabled” by SSDI (going on 6 months now). I worked. She played and did drugs. While I am happy that she is now “clean and sober for 5 years”, she has no health issues but still gets over $1000 a month, over $200 in food stamps and free health care that she uses ABUSES almost DAILY between multiple ER’s she hops around to which she learned from her mother who did the same until she died from prescription drug abuse. This being said, I have a difficult time feeling sorry for those who want to sit in the ER all day because they CAN since they don’t work and are looking for prescription meds and tests/procedures the rest of us have to pay for. A copay for non emergency ER visits would definitely put a stop to the abuse the taxpayers all pay for.

      Reply
      • Karen, thanks for commenting. I hope you feel better and get everything worked out. The idea of a copay or surcharge has been around since I was a resident. It will never happen. Whoever sponsored legislation for it would be committing political suicide.

        Reply
  8. Unfortunately this isn’t particularly novel. It works in many settings and is often a difficult sell to admin. Any experience getting the c suite to invest in this type of program?

    Reply
    • I have no experience with this. Perhaps some readers will comment

      Reply
  9. Really?? !! Referral to Primary Care, Social services, Substance Abuse programs. In my35 years of ER experience: They come to the ER whenthey want to, regardless of ANY INTERVENTION!!

    Reply
    • That has been my experience too. I was merely reporting the Baltimore Sun story. Maybe it works there.

      Reply
      • I disagree, it is intuitive that these people have nothing better to do but simply not true. IF you force everyone to give these people attention they they can be less of a problem- most of the people who are being cynical are not addressing the huge COST of the program, I usually don’t have time to address ANY of their underlying issues or the secondary gain, but social work works, I know I am on the line(not today VACATION)

        Reply

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