I like to think the reason Mainers use emergency departments more frequently than most other Americans is because I work there at night and these people want to come see me. It is all about me, after all. But this high rate of emergency department use, and its high cost, has led many of us health policy nut jobs, employers, insurers and state government officials to target unnecessary emergency department use as a way to save money in health care, and rightly so.
However, keeping people out of the ED is harder than keeping a dog out of the trash, for several reasons that must be understood if the problem is to be solved. A simplistic perception of the problem will lead to simplistic solutions that will not work, instead of the steady application of multiple strategies over a very long haul.
Most importantly, it must be recognized that patients who use the ED “unnecessarily” are a complex group with varied needs, and no one solution for encouraging them to get care elsewhere fits all of them. Each patient type requires an alternative system of care to the ED.
For example, if a 20-year-old working mom of a child with a fever and ear pain is not going to go to the ED at 1 a.m. she needs some other way to get medical advice before coming to the ED, reassurance that the child probably does not need antibiotics right now, and pain medication all at 1 a.m. She needs access to the child’s regular medical care during hours of the day when she is not working and has transportation. She might need a financial disincentive to using the ED (like a small co-payment) and assurance that if she does not take the child to the ED at night the child can be seen by the family physician early the next day. None of that help is con-sistently available to every such mom in Maine.
On the other hand, the patient with mental illness who comes into the ED 30 times a year feeling depressed and scratching his wrists with broken glass needs community access to a good crisis worker, a regular counselor, family and community support, someone to ensure he takes his prescribed psychiatric medications, a physi-cian, etc. None of that help is consistently available to every such patient in Maine either.
The whole category of patients that ED staff call “frequent fliers” — those who visit EDs frequently — contributes substantially to ED overuse. Most are chronically and severely ill with either mental illness or multiple chronic medical conditions such as heart failure. They have a rate of death two to three times that of the gen-eral population — most really are sicker than the rest of us and some hang by the proverbial thread. They often have one foot in the ED because they fear the other foot hovers near the grave. Multiple studies of methods to keep them out of EDs have had uneven results, but the most successful programs use intensive outpatient management from primary care providers, nurse case managers and families.
A key source of alternative care for all of these patient types is primary care providers — nurse practitioners, internists, pediatricians, family docs and physician assistants. Paradoxically, at the same time state officials have identified the need for better access to PCPs to reduce ED use as a way to control health care costs, the state is proposing to cut reimbursement to more than half of the PCPs in Maine (those, such as me, who are employed by Maine hospitals). Shooting ourselves in our PCP foot this way will not help reduce ED overuse.
Programs to reduce ED use must provide access to alternative care in the evening and on weekends, when EDs are at their busiest because they are often the only game in town. Reducing unnecessary ED use is a laudable goal that will take a comprehensive, long-term, broad-based individualized initiative into which we will have to put money (especially into coordinated community care alternatives), time, effort, malpractice reform and multistakeholder support. I’ll believe it when I see it, and until then, I am happy to see you tonight in the ED.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region. He is also the interim CEO at Blue Hill Memorial Hospital.